RMKS/PART A NON-PRIVILEGED GENERAL INFORMATION
A.GENERAL INFORMATION
1. REPORTING ACTIVITY UIC/MCC/RUC: ______
2. SERIAL NUMBER ASSIGNED BY THE REPORTING COMMAND: ______
3. LOCAL TIME OF MISHAP: ______
4. DATE OF MISHAP: ______
5. TYPE OR CATEGORY OF MISHAP EVENT: ______
6. LOCATION OF MISHAP EVENT
(A) COUNTY: ______
(B) TOWNSHIP: ______
(C) CITY: ______
(D) STATE: ______
(E) COUNTRY: ______
(F) ROAD/STREET/INTERSTATE/ROUTE DESIGNATION: ______
7. MISHAP NARRATIVE/LESSONS LEARNED/RECOMMENDATIONS:
______
______
8. CLASSIFIED SUPPLEMENT SUBMITTED: ______
9. ON OR OFF BASE: Not on Govt. Base or Vessel
10. UIC/MCC/RUC WHERE MISHAP OCCURED, IF ON GOV'T PROPERTY: ______
11. UNIT EMPLOYMENT
(A) PROVIDE EXERCISE OR OPERATION NAME, IF APPLICABLE: ______
(B) DATE LEFT HOME PORT AND/OR DATE LEFT LAST PORT: ______
LEFT HOME PORT: ______
LEFT LAST PORT: ______
(C) GENERAL STATUS: ______
(D) SPECIFIC UNIT EVOLUTION: ______
(E) PAYLOAD
(1) TYPE CARGO: ______
(2) LOAD WEIGHT (TONS): ______
12. SHIP BASED ACTIVITIES
(A) SHIP ACTIVITY: ______
(1) IS THIS ACTIVITY DEPLOYED: ______
(2) NAVY LEVEL OF COMMAND: ______
13. UNIT EMPLOYMENT
(A) PROVIDE EXERCISE OR OPERATION NAME, IF APPLICABLE: ______
(B) DATE LEFT HOME PORT AND/OR DATE LEFT LAST PORT
LEFT HOME PORT: ______
LEFT LAST PORT: ______
(C) GENERAL STATUS: ______
(D) SPECIFIC UNIT EVOLUTION: ______
(E) PAYLOAD
(1) TYPE CARGO: ______
(2) LOAD WEIGHT (TONS): ______
14. SHIP BASED ACTIVITIES: ______
(A) SHIP ACTIVITY: ______
(1) IS THIS ACTIVITY DEPLOYED: ______
(2) NAVY LEVEL OF COMMAND ECHELON 2: ______
(3) NAVY LEVEL OF COMMAND ECHELON 3: ______
15. SHORE BASED ACTIVITIES: ______
(A) SHORE ACTIVITY: ______
(1) IS THIS ACTIVITY DEPLOYED: ______
(2) NAVY LEVEL OF COMMAND: ______
16. MISHAP ENVIRONMENT
(A) SEA STATE AND DIRECTION: ______
(B) WIND DIRECTION AND SPEED (KNOTS): ______
(C) AIR TEMPERATURE (F): ______
(D) WATER TEMPERATURE (F): ______
(E) WET BULB GLOBE TEMPERATURE: ______
(F) VISIBILITY: ______
(G) VISIBILITY REDUCED BY: ______
(H) LIGHTNING: ______
(I) CUMULATIVE PRECIPITATION: ______
(J) LIGHTING CONDITIONS/AVAILABILITY AT SITE OF MISHAP: ______
(K) NOISE LEVEL A FACTOR: ______
(L) SOURCE OF FIRE/COMBUSTION: ______
(M) WAS CARBON MONOXIDE A FACTOR: ______
(1) CO ALARM MANUFACTURER: ______
(2) CO ALARM MAKE AND MODEL: ______
(3) CO ALARM LAST TESTED ON (DATE): ______
(4) LAST CO ALARM INSPECTION ON MAINTENANCE SCHEDULE: ______
B. PERSONNEL INVOLVED INFORMATION
1. NAME: ______
2. SOCIAL SECURITY NUMBER: ______
3. DATE OF BIRTH: ______
4. AGE: ______
5. SEX: ______
6. HEIGHT: ______
7. WEIGHT: ______
8. MARITAL STATUS: ______
9. BADGE NUMBER, SHOP OR DEPT: ______
10. SHIFT: ______
11. SERVICE: ______
12. SERVICE STATUS: ______
13. DUTY STATUS: ______
14. PAY GRADE: ______
15. IS THIS PERSON DEPLOYED: ______
16. FIRST LINE SUPERVISOR'S NAME, BADGE NUMBER AND RANK/RATE/GRADE: __
17. SECOND LINE SUPERVISOR'S NAME, BADGE NUMBER AND RANK/RATE/GRADE: _
18. PARENT UIC/MCC/RUC: ______
19. PROTECTIVE EQUIPMENT : ______
20. ALCOHOL USE/BAC: ______
21. DRUG USE: ______
22. JOB, SKILL OR ACTIVITY INDIVIDUAL ENGAGED IN AT TIME OF MISHAP: __
23. QUALIFICATIONS FOR JOB ACTIVITY
(A) NUMBER OF YEARS, MONTHS OR DAYS EXPERIENCE AT THE SPECIFIC
ACTIVITY/SKILL/JOB ENGAGED IN AT TIME OF MISHAP: ______
(B) QUALIFICATIONS, DESIGNATIONS, LICENSES AND/OR CERTIFICATIONS
LEVEL HELD FOR THE SPECIFIC ACTIVITY/SKILL/JOB ENGAGED IN AT TIME
OF MISHAP ______
(C) LIST RESTRICTIONS TO LICENSE OR REASON FOR REVOKING
CERTIFICATION ______
(D) EXPIRATION DATE ______
(E) LIST SAFETY COURSES ATTENDED AND DATES COMPLETED AS RELATED TO THE MISHAP ______
24. MISHAP LOCATION ______
(A) SHORE/GROUND LOCATION ADMINISTRATIVE AREAS:______
25. MISHAP CAUSE CODE(S) APPLICABLE TO THE INVOLVED PERSON: ____
26. CAUSE CODE NARRATIVE: ______
C. PERSONNEL INVOLVED INFORMATION
1. NAME: ______
2. SOCIAL SECURITY NUMBER: ______
3. DATE OF BIRTH: ______
4. AGE: ______
5. SEX: ______
6. HEIGHT: ______
7. WEIGHT: ______
8. MARITAL STATUS: ______
9. BADGE NUMBER, SHOP OR DEPT: ______
10. SHIFT: ______
11. SERVICE: ______
12. SERVICE STATUS: ______
13. DUTY STATUS: ______
14. PAY GRADE: ______
15. IS THIS PERSON DEPLOYED: ______
16. FIRST LINE SUPERVISOR'S NAME, BADGE NUMBER AND RANK/RATE/GRADE: __
17. SECOND LINE SUPERVISOR'S NAME, BADGE NUMBER AND RANK/RATE/GRADE: _
18. PARENT UIC/MCC/RUC: ______
19. PROTECTIVE EQUIPMENT ______
20. ALCOHOL USE/BAC: ______
21. DRUG USE: ______
22. JOB, SKILL OR ACTIVITY INDIVIDUAL ENGAGED IN AT TIME OF MISHAP: ______
23. QUALIFICATIONS FOR JOB ACTIVITY
(A) NUMBER OF YEARS, MONTHS OR DAYS EXPERIENCE AT THE SPECIFIC ACTIVITY/SKILL/JOB ENGAGED IN AT TIME OF MISHAP: ______
(B) QUALIFICATIONS, DESIGNATIONS, LICENSES AND/OR CERTIFICATIONS
LEVEL HELD FOR THE SPECIFIC ACTIVITY/SKILL/JOB ENGAGED IN AT TIME
OF MISHAP: ______
(C) LIST RESTRICTIONS TO LICENSE OR REASON FOR REVOKING
CERTIFICATION ______
(D) EXPIRATION DATE ______
(E) LIST SAFETY COURSES ATTENDED AND DATES COMPLETED AS RELATED TO THE MISHAP: ______
24. MISHAP LOCATION
(A) SHORE/GROUND LOCATION NON-PERMIT REQUIRED AREA : ______
25. MISHAP CAUSE CODE(S) APPLICABLE TO THE INVOLVED PERSON: ______
ALIGNMENT/ADJUSTMENT REQUIRED
26. CAUSE CODE NARRATIVE: ______
D. PROPERTY DAMAGE
1. PROPERTY DAMAGE IN U.S. DOLLARS: ______
(A) U.S. GOVT. OWNED: ______
(B) NON-U.S. GOVT. OWNED: ______
2. NUMBER OF MISSION DAYS LOST: ______
3. PROPERTY/EQUIPMENT DAMAGED OR DESTROYED BY THE MISHAP ______
(A) NON-U.S. GOVT. ______
(1) NAME: ______
(2) DESCRIPTION: ______
(3) MAKE: ______
(4) MODEL AND SERIES: ______
(5) YEAR: ______
(6) SERIAL NUMBER: ______
(7) PROPERTY/EQUIPMENT OWNER: ______
(8) PROPERTY/EQUIPMENT USER IF DIFFERENT THAN OWNER: ______
4. IS THIS PROPERTY DEPLOYED: ______
5. OWNERSHIP STATUS: ______
(1) NAVY LEVEL OF COMMAND: ______
6. MISHAP CAUSE CODE(S) APPLICABLE TO THE MATERIAL DAMAGE: ______
7. CAUSE CODE NARRATIVE: ______
(A) NON-U.S. GOVT. ______
(1) NAME: ______
(2) DESCRIPTION: ______
(3) MAKE: ______
(4) MODEL AND SERIES: ______
(5) YEAR: ______
(6) SERIAL NUMBER: ______
(7) PROPERTY/EQUIPMENT OWNER: ______
(8) PROPERTY/EQUIPMENT USER IF DIFFERENT THAN OWNER: ______
8. IS THIS PROPERTY DEPLOYED: ______
9. OWNERSHIP STATUS: ______
(1) NAVY LEVEL OF COMMAND: ______
10. MISHAP CAUSE CODE(S) APPLICABLE TO THE MATERIAL DAMAGE: ______
ITEM PHYSICALLY DAMAGED
11. CAUSE CODE NARRATIVE: ______