TE 2 - Forms - Ground Mishap Statement.pdf

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1. NAME OF WITNESS (LAST, FIRST, MI)

5. ADDRESS (Include ZIP Code) (If military, include organization)

8. EXPERIENCE AND BACKGROUND

13. DATE OF ACCIDENT (YYYYMMDD)

12. SUMMARY OF INTERVIEW

2. OCCUPATION/TITLE

9. LOCATION AT TIME OF ACCIDENT

6. TELEPHONE NUMBER (Duty/Work)

7. DATE OF INTERVIEW (YYYYMMDD)

10. INTERVIEWER (Name and Grade)

3. GRADE

4. DATE OF BIRTH

a. Was a promise of confidentiality offered to the witness?

blk 15. If no, read blk 14b. to the witness.)

b. Confidentiality was requested by the witness.

For use of this form, see DA Pamphlet 385-40; the proponent agency is DAS.

No

DA FORM 285-W, JUL 2023

PREVIOUS EDITIONS ARE OBSOLETE.

APD AEM v1.00ES

REQUIREMENTS CONTROL SYMBOL CSOCS-308

Yes Yes (If yes, interviewer sign and date statement below.)

THE WITNESS MADE THIS STATEMENT UNDER A PROMISE OF CONFIDENTIALITY.

11. Promise of confidentiality. A promise of confidentiality can only be offered in Limited Use Investigations, which normally are not ground accidents. For exception, see AR 385-10, paragraph 3-10.

TECHNICAL REPORT OF U.S. ARMY GROUND MISHAP SUMMARY OF WITNESS INTERVIEW

SIGNATURE OF INTERVIEWER

DATE (YYYYMMDD)

AUTHORITY: 10 U.S.C. 7013, Secretary of the Army, 5 USC 7902, Safety Programs, and AR 385-10, The Army Safety and Occupational Health Program.

PRINCIPAL PURPOSE(S): The mishap investigator has in determining the sequence of events and mishap causal factors. The form is used to interview witnesses, which is an integral part of the investigation process, if there are witnesses present. For additional information, see the System of Records Notice A0385-1040 ASO, https://www.federalregister.gov/documents/2020/02/27/2020-03949/privacy-act-of-1974-system-of-records.

ROUTINE USES: There is no specific routine uses anticipated for this form; however, it may be subject to a number of proper and necessary routine uses identified in the system of records notice(s) specified in the purpose statement above.

DISCLOSURE: Voluntary. However, the use of witness information is a critical part of the overall investigation process. Failure to provide the information will interfere with the mishap investigation. This will interfere with the understanding of the mishap and possible lessons learned to prevent the mishap from reoccurring.

PRIVACY ACT STATEMENT

(If yes, read blk 14a. to the witness and complete No

a. Promise of confidentiality offered.

(1) This accident investigation board has been convened under the provisions of Army Regulation 385-10 for the purpose of conducting a safety investigation.

(2) This may be just one of a number of investigations being conducted regarding this accident; collateral or legal investigations may be ongoing as well. Those investigations are entirely separate from a safety investigation and are also required to inform you of their purpose and of your legal rights.

(3) This safety investigation is being conducted for accident prevention purposes only. Within the military, pursuant to AR 385-10, it cannot be used for any other purpose, to include any future disciplinary actions against any individuals. Therefore, the interview you are being asked to provide will be used by the Army in the interest of safety and accident prevention only.

(3) Nonconfidential witness interviews may be released to the public pur-suant to a Freedom of Information Act request. If you wish to protect your interview from public release outside the military, then your inter-view must be pursuant to a promise of confidentiality. Confidentiality means that your interview will not be released to the public or outside DoD safety channels.

(5) Whether your interview is confidential or not, the chain of command will review the final accident report, which may include a summary of your interview, but the chain of command may only use the investigation report and the interviews for safety and accident prevention purposes.

(6) If you ever have knowledge that your witness interview was used by the Army for anything other than accident prevention purposes (for example, disciplinary action against an individual), you should consult with your local Judge Advocate Defense Counsel Office and request that the Command Judge Advocate, U.S. Army Combat Readiness Center, be notified at DSN 558-2924 or commercial (334) 255-2924.

(7) The promise of confidentiality is available to you if you desire it. Do you desire it?

DA FORM 285-W, JUL 2023

APD AEM v1.00ES

14. GENERAL WITNESS INFORMATION BRIEFING (Interviewer must read appropriate instructions to the witness)

15. AVAILABILITY OF PROMISE OF CONFIDENTIALITY FOR "LIMITED USE" REPORT OF INVESTIGATION

b. No promise of confidentiality offered.

(1) This accident investigation board has been convened under the provisions of AR 385-10 for the purpose of conducting a safety investigation.

(2) This may be just one of a number of investigations being conducted regarding this accident; collateral or legal investi-gations may be ongoing as well. Those investigations are entirely separate from a safety investigation and are also required to inform you of their purpose and of your legal rights.

(3) This safety investigation is being conducted for accident prevention purposes only. Within the military, pursuant to AR 385-10, it cannot be used for any other purpose, to include any future disciplinary actions against any individuals. Therefore, the interview you are being asked to provide will be used by the Army in the interest of safety and accident prevention only.

(4) The chain of command will review the final accident report, which may include a summary of your interview, but the chain of command may only use the investigation report and the interviews for safety and accident prevention purposes. The interview summary may be released to the public pursuant to a Freedom of Information Act request.

(5) If you ever have knowledge that your witness interview was used by the Army for anything other than accident prevention purposes (for example, disciplinary action against an individual), you should consult with your local Judge Advocate Defense Counsel Office and request that the Command Judge Advocate, U.S. Army Combat Readiness Center, be notified at DSN 558 -2924 or commercial (334) 255-2924.

I request a promise of confidentiality. I understand that the results of my interview will be used within the military only for the I decline a promise of confidentiality. I understand that the results of my interview will be used within the military only for

a. Pursuant to AR 385-10, witness interviews may only be used within the military for purposes of accident prevention, and may not be used as evidence in connection with any administrative or disciplinary proceeding. This protection alone does not prevent release of the interview outside of the military (to the public, newspapers, attorneys, etc.) under the Freedom of Information Act. If you wish to protect your interview from release outside of the military, then your interview must be pursuant to a promise of confidentiality.

b. If you do not wish a promise of confidentiality, you may decline such below. In that case, your interview will still be used in the military only for purposes of accident prevention, but it may be released outside of the military in response to a Freedom of Information Act request. Please indicate which option you desire by initialing one of the choices below:

purposes of accident prevention, and will also be protected from public release outside of the military under the Freedom of Information Act.

purposes of accident prevention. I also understand that the results may be publicly released outside of the military under the Freedom of Information Act.

Name of witness (Print Name - do not sign)

1.00ES

DA FORM 285-W, JUL 2023

TECHNICAL REPORT OF U.S. ARMY GROUND MISHAP - SUMMARY OF WITNESS INTERVIEW

APD

Information Act. : No