Form Ds-1663 - Report Of Mishap - U.s. Department Of State Page 2
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2COMPLETE THIS FORM TO REPORT ALL MISHAPS RESULTING IN INJURIES, INCLUDING INJURIES FROM OFFICIAL VEHICLE MISHAPS, ILLNESSES, OR ENVIRONMENTAL CONTAMINATION
III. INJURY/ILLNESS INFORMATION
U.S. Department of State
13. Severity of Injury or Illness (Check all that apply)
REPORT OF MISHAP
First Aid
Permanent
Lost Time/
I. MISHAP INFORMATION
Fatal
Medical Attention
Restricted Duty
Disability
3. Organizational Symbol
(Other than First Aid)
2. Post/City, State
1. Agency
14. Fatal - Date of Death (if after date of mishap - mm-dd-yyyy)
4. Type of Mishap (Check all that apply)
15. Medical Attention
Environmental Contamination
Illness/Injury
Property Damage
Inpatient Hospitalization
Emergency Room
5. Date of Mishap (mm-dd-yyyy)
6. Time of Mishap (hh:mm)
a.m.
16. Cause of Mishap
p.m.
7. Location of Mishap (Check all that apply)
17. Nature of Injury or Illness (contusion, laceration, sprain, fracture, muscle strain, etc.)
a. Type:
Other
USG Facility
USG Residence
b. Ownership:
Gov. Owned/Capital Lease
Operating Lease
LQA
18. Body Part(s) Injured
Specific Location
19. WORK-RELATED EMPLOYEE INJURIES ONLY:
8. Detailed Description of Mishap/Property Damage (please attach Form DS-1664 if Motor Vehicle)
a. Calendar Days Lost
b. Days Restricted Duty
c. Name of treating physician/health care provider
d. Treatment facility name and address (if off-site)
e. Employee's Date of Hire (mm-dd-yyyy)
a.m.
p.m.
f. Employee's Shift Start Time (hh:mm)
IV. PROPERTY DAMAGE INFORMATION
21. Type of Property
22. Property Status
20. Est Amount of Property Damage
USG owned
V. CORRECTIVE ACTION
II. PERSONAL INFORMATION
23. Describe recommended action(s) that will prevent the recurrence of a similar mishap in the future,
9. Name of Individual (Last, First, MI.)
and whether or when these actions have been implemented.
TDY
10. Gender (Check one)
11. Date of Birth (mm-dd-yyyy)
Male
Female
12. Category (Check one)
GS
FS
FSN
PSC
CON
EFM
Other
Post-managed Contractor?
Job/Activity
VI. SUPERVISOR/POSHO INFORMATION
POSHO's Name and Title
Supervisor's Name
Supervisor's Signature
Date (mm-dd-yyyy)
POSHO's Signature
Date (mm-dd-yyyy)
DS-1663
07-2017
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