Incident Mishap Reporting Record Form Page 3

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Privacy Act Notice
Authority: 5 U.S.C. 301, 29 CFR, and COMDTINST M5100.47 authorizes the collection of this information.
Purpose: The Coast Guard will use this information to conduct an assessment of the safety and environmental health risk
management process for the incident and unit.
Routine Uses: The information will be used by and disclosed to Coast Guard personnel and contractors or other agents
who need the information to assist in activities related to safety and environmental health for the incident and unit.
Disclosure: Furnishing this information is mandatory for Coast Guard Active, Reserve, Auxiliary and Civilian personnel as
well as Coast Guard contracted personnel and is voluntary for all others; however, failure to furnish the requested
information may increase safety and environmental health risks.

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