Incident Mishap Reporting Record Form Page 2
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3INCIDENT MISHAP REPORTING RECORD (ICS 237-CG Rev 7/13)
Purpose. This record is designed to record incident MISHAPs. This is used only when directed by the incident Safety Officer. This is a
Coast Guard specific form to comply with COMDTINST M5100.47 during incident response. This is not a replacement for the MISHAP
system used by parent commands.
Preparation. The “Incident MISHAP Reporting Record” is initiated when documenting any of the following: injury, illness, property
damage, or high potential (HIPO) accident occurrence. Use additional records for multiple members injured or suffering illness from one
occurrence. Information contained in this form is considered For Official Use Only (FOUO).
Distribution. The Person filling out the record submits this form as MISHAPS occur (as required). The original and first copy goes to the
incident Safety Officer, the second copy is kept by the person completing the record (member). The incident Safety Officer or assistant
(CG member) will enter appropriate information in CG e-MISHAP reporting system and send the first copy to Health Safety Work-Life
Service Center, Safety & Environmental Health (HSWL SC-SE).
Item # Item Title
Instructions
1. Incident
Enter the name assigned to the incident.
2. Date/Time
Enter the date and time of the MISHAP
3. Location
Enter location on the incident MISHAP occurred (e.g. ICP, DIV A, LAT/LONG, etc.)
4. Local CG Command Enter the CG command/unit where the injured person or damaged property assigned/working.
5. OPFAC
Enter the OPFAC of the local command (if known).
6. Name of Injured
Enter last name (PRINT), first name and middle initial of injured person (if applicable)
7. Age
Enter age of injured person (if applicable).
8. M/F
Circle appropriate sex of injured person (if applicable)
9. Rank/Rate/Grade
Enter Rank/Rate (military), Grade (CG civ) or Auxiliarist of injured person (if applicable).
10. Narrative of MISHAP Describe circumstances surrounding the injury/illness or property damage and describe operations being
conducted.
11. Body part injured
If applicable/known: Check box and/or describe the part(s) of body injured or illness suffered; Check box and/
/Nature of injury
or describe nature of injury or illness; Enter days hospitalized, lost work days, and/or days restricted duty; Circle
and/or describe the Personal Protective Equipment (PPE) Required (R) and/or utilized (U) at time of MISHAP.
12. List of Damaged
If applicable/known: Check Box for CG property or non-CG property; Enter Operational Days Lost; estimated
Property/Est Cost
cost; Check box for kind of property and/or describe damage to property.
13. Signature
Signature of person completing the record.
14. Name
Name of person completing form.
15. Rank/Rate/Grade
Enter Rank/Rate (military)/Grade (CG civ) or Auxiliarist of person completing the record.
16. ICS Position
Enter ICS Position held by the person completing the record.
17. Email
Email of person completing the record.
18. Report Number
Locally generated number to assist in tracking MISHAP reports.
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