Form Ds-1663 - Report Of Mishap - U.s. Department Of State

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REPORT OF MISHAP INSTRUCTIONS

For mishaps causing injury or illness to more than one individual, complete and attach a DS-1663

(with only sections 1-19 completed) for each additional individual.

I. MISHAP INFORMATION

17. Nature of Injury or Illness - Indicate the type of injury (or property

damage) or illness, such as 2nd degree burn, fracture, abrasion, contusion,

1. Agency - Agency of injured individual or agency reporting damaged

amputation, hearing loss, irritation, cancer, liver disease, contamination,

property.

etc.

2. Post/City, ST - Provide post name for overseas mishaps, US City and

State for domestic mishaps.

18. Body Part(s) Injured - Indicate the body parts(s) injured, such as lower

3. Organizational Symbol - For domestic mishaps only, provide office

arm, ankle, ribs, neck, head, eye, hearing, liver, respiratory tract, etc.

symbol of injured individual or office reporting damaged property.

(Leave blank for property damage mishaps).

4. Type of Mishap - Check one or more types that apply to this mishap.

19. WORK-RELATED EMPLOYEE INJURIES ONLY

For "Environmental Contamination," see NOTE.

a. Estimated Calendar Days Lost from work - A count of all calendar days

5. Date of Mishap - Enter the date of mishap as mm-dd-yyyy. For illnesses

(consecutive or not), including weekend days and holidays, after, but not

(e.g., cumulative trauma), enter the date of diagnosis or onset of disability,

including, the day of injury or illness onset, where the employee would

have

whichever is earlier.

worked but could not because of the injury or illness.

6. Time of Mishap - Enter time as hh:mm. Check a.m. or p.m.

b. Estimated Days Restricted Duty - The number of days when the

7. Location of Mishap - Check all the appropriate boxes that apply for

employee could not perform any or all of his or her normal assignment

property type and ownership of USG facility or residence. Then briefly

during all or any part of the workday or shift, because of the injury or illness.

describe the specific location on the property (e.g., warehouse, swimming

c. Name of treating physician/health care provider - Self Explanatory

pool, cafeteria, office area, bedroom).

8. Detailed Description of Mishap - Describe in as much detail as possible,

d. Treatment facility name and address (if off-site) - Self Explanatory

the who, what, where, when, why and how of the mishap. Include relevant

e. Employee's Date of Hire - Enter the date as mm-dd-yyyy.

remarks about weather, equipment or tools involved, unsafe conditions,

acts and personal factors and whether other persons may have

f. Employee's Shift Start Time - Enter as hh:mm.

contributed to the accident. For environmental mishaps, describe the

IV. PROPERTY DAMAGE INFORMATION

failures (equipment or personnel) that led to the release of chemicals or

pollutants.

20. Estimated Amount of Property Damage - Self Explanatory.

Leave blank for injury/illness mishaps.

II. PERSONAL INFORMATION

21. Type of Property - Such as building, residence, GOV, POV, personal

9. Name of Individual - Self Explanatory. Check the "TDY" box if employee

property, security barrier, etc.

was on a temporary duty assignment when the mishap occurred.

22. Property Status - Check if property is government owned.

10. Gender - Self Explanatory.

V. CORRECTIVE ACTION

11. Date of Birth - Enter date of injured individual's birth as mm-dd-yyyy.

23. What Corrective Action Has Been or Will Be Implemented - Describe

action(s) to be taken that will prevent the recurrence of similar mishaps in the

12. Category and Job/Activity - For employees, check one personnel

future. Indicate whether actions have been implemented, or estimated date of

category and provide the injured employee's job title or a brief job

when actions will be implemented.

description. (FS - Foreign Service, GS - General Service, FSN - Foreign

Service National, EFM - Eligible Family Member, PSC - Personal Services

VI. SUPERVISOR/POSHO INFORMATION

Contractor, CON - Contractor. For Other - enter brief description (e.g.,

Signatures - The POSHO must review and sign off on the DS-1663.

family member, local national)). Check the "Post-Managed Contractor?"

box

FILING INSTRUCTIONS

if the contractor is being managed by Post personnel, versus OBO

personnel on an OBO-managed project.

Overseas

Domestic

Send the completed form to the Post

Director, DESD (A/OPR/FMS/DESD)

III. INJURY/ILLNESS INFORMATION

Occupational Safety and Health

2201 C Street, NW

Officer (POSHO) at your Post. If that's

Washington, DC 20522-6011

13. Severity of Injury or Illness - Check all that apply. For "Fatal",

not possible, scan and email a copy

or by Fax to 202-647-1873

"Permanent Disability", see NOTE. For "Lost time/Restricted Duty, enter

to OBO/OPS/SHEM at:

the number of days in block 17. "Medical Attention Other than First Aid"

SHEM-MRSAdmin@state.gov

are mishaps that do NOT result in lost time from work, but where medical

treatment is administered by a physician or registered professional

Workers' Compensation Claim Filing - Do NOT send CA-1 or CA-2 forms to

personnel under the orders of a physician. First Aid treatment (i.e.,

OBO/OPS/SHEM. Employees need to file claims electronically using the

one-time treatment of minor scratches, cuts, burns, splinters and so forth)

Department of Labor's ECOMP system. Contact HR/ER/WLD for additional

does not ordinarily require medical care, even if administered by a

information:

physician or registered professional.

Workers' Compensation Program

14. Fatality - Enter date of death if after date of mishap as mm-dd-yyyy.

NOTE: The following categories of mishaps must be reported within

15. Medical Attention - Inpatient hospitalization means being admitted to the

12 hours as per 15 FAM 964.4-1:

hospital for at least one overnight stay resulting from the injury/illness. For

* Injury or occupational illness resulting in a fatality, permanent

"Emergency Room" medical care, check for any instances where the

total disability or inpatient hospitalization;

patient used emergency room services.

* Property damage of $50,000 or more;

16. Cause of Mishap - Identify the event that resulted in the injury or illness

* Operations curtailed or shut down for more than 8 hours;

(such as falling from, struck by, lifting, inhaling) and the object or source

* Injuries or occupational illnesses (with lost workdays), involving

involved (such as ladder, tool, chemical). For property damage or

three or more employees;

environmental contamination, provide the event and source leading to the

damage/contamination.

* Any environmental contamination.

PRIVACY ACT STATEMENT

AUTHORITY: The Occupational Safety and Health Act of 1970 (29 U.S.C. 657, 673); Secretary of Labor's Order No. 12-71 (36 FR 8754), 8-76 (441 FR 25059),

or 9-83 (48 FT 35736) and Code of Federal Regulations, Occupational Safety and Health Administration, Labor (29 1904, 1-22).

The DS-1663, Report of Mishap (15 FAM 963) is required whenever a mishap occurs on Department owned or leased property or during the conduct of U.S.

Government business. Reporting is required when mishaps result in personal injury (excluding a minor injury requiring to only first aid treatment), property

damage in excess of $1,000 or any environmental contamination.

PURPOSE: The principal purpose of the Report of Mishap is to inform safety and health officials of all serious occupational injuries, illnesses, and environmental

contamination incidents. Sufficient details must be provided to help prevent future occurrences. It is also used to insure that supervisors are aware of their

safety/health responsibilities.

ROUTINE USES: These reports are used to provide statistical information to the Department of Labor in the Department's Safety and Occupational Health

Annual Report. This report is designed to document and measure the progress of the safety program. Mishap reports are reviewed during program

assessments and to focus training/assistance efforts on the information contained therein.

DS-1663

Instruction Page 1 of 1

07-2017