Incident Mishap Reporting Record Form
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3INCIDENT MISHAP REPORTING RECORD (ICS 237-CG rev 07/13)
1. Incident: ____________________
2. Date/Time: ____________ 3.Location: _______________________________ 4. CG Unit: _____________________________
5.
__________ 6
_____________________________ 7.Age:____ 8. M / F 9.Rank
:_______
OPFAC:
Name of Injured:
/Rate/Grade
.
(If Applicable – Print Last, First, MI)
(If known)
(If Applicable)
(circle)
(If Applicable)
10. Narrative of Mishap: _____________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
□ Abdomen □ Chest
□ Back
□ Lungs
□ Int. Organs □ Head
11. Part(s) of Body Injured (if applicable):
□ Neck
□ Eyes □ Ear
□ Hip/Pelvis □ Leg □ Knee
□ Ankle
□ Foot
□ Toes
□ Shoulder
□ Arm
□ Elbow □ Hand □ Wrist □ Finger
□ Other
_______________________________________________________
_____
______
______
Days Hospitalized:
Lost Work Days (NFFD/SIQ):
Days Restricted (FFLD):
Nature of Injury:
□ Abrasion
□ Concussion
□ Paralysis
□ Bruise
□ Cut
□ Puncture
□ Sprain
□ Absorption
□ Ingestion
□ Burn
□ Amputation
□ Dislocation
□ Fracture
□ Inhalation
□ Gunshot Wound □ Electrical Shock □ Loss of Consciousness
□ Occupational Illness
Personal Protective Equipment (PPE): Circle R = PPE Required and/or U = PPE Utilized
R / U - Hearing
R / U - Seat Belt
R / U - Head
R / U - PFD
R / U - Hand
R / U - Eye
R / U - Foot
R / U - Respirator R / U - Fall/Harness R / U - Other: ___________________________________________
12. Damaged Property/Estimated Cost □ CG Property
□ Non-CG Property Op Days Lost: ______
Cost Est $________
□ Aircraft
□ Aton
□
□ Buildings
□
□
□
□
Boats
Cutter
Equipment
Piers
Vehicles
List Damaged Property: ____________________________________________________________________________________
13. Signature: _____________________________ 14. Name: _____________________________ 15.
_________
Rank/Rate/Grade:
(Person completing form – Print)
(Person completing form)
16. ICS Position: _______________________ 17. Email: __________________________________ 18. Report #: ____________
(Person completing form – Print)
(Person completing form – Print)
.
Original - Safety Officer
Copy 1 - HSWL Service Center (se)
Copy 2 - Retained by member
FOR OFFICIAL USE ONLY (FOUO) -
https://hswl.uscg.mil/
SEE PRIVACY ACT NOTICE
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