Start display at page:. This document should be reissued by the chief of mission or by the miishap post safety and health administrator whenever there is a change in the administrator or the POSHO. The administrator will issue appropriate SHEM information, procedures, requirements, etc. Michigan Occupational Safety and Health Act Introduction Every year, accidents in the work place cause serious injuries and loss of life.

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This is a legal form that was released by the U. Department of State on May 1, and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Download a fillable version of Form DS by clicking the link below or browse more documents and templates provided by the U. Department of State. Download the document to your desktop, tablet or smartphone to be able to print it out in full. What Is Form DS? Department of State; Easy to use and ready to print; Yours to fill out and keep for your records; Compatible with most PDF-viewing applications; Download a fillable version of Form DS by clicking the link below or browse more documents and templates provided by the U.

Rate 4. Show Pagination. For mishaps causing injury or illness to more than one individual, complete and attach a DS Nature of Injury or Illness - Indicate the type of injury or property. Agency - Agency of injured individual or agency reporting damaged.

Body Part s Injured - Indicate the body parts s injured, such as lower. Organizational Symbol - For domestic mishaps only, provide office.

Type of Mishap - Check one or more types that apply to this mishap. Estimated Calendar Days Lost from work - A count of all calendar days. Date of Mishap - Enter the date of mishap as mm-dd-yyyy. For illnesses. Time of Mishap - Enter time as hh:mm. Check a. Estimated Days Restricted Duty - The number of days when the.

Location of Mishap - Check all the appropriate boxes that apply for. Then briefly. Detailed Description of Mishap - Describe in as much detail as possible,. Treatment facility name and address if off-site - Self Explanatory. Include relevant. Employee's Date of Hire - Enter the date as mm-dd-yyyy.

For environmental mishaps, describe the. Name of Individual - Self Explanatory. Check the "TDY" box if employee. Property Status - Check if property is government owned. Date of Birth - Enter date of injured individual's birth as mm-dd-yyyy. Indicate whether actions have been implemented, or estimated date of.

Contractor, CON - Contractor. For Other - enter brief description e. Check the "Post-Managed Contractor? Severity of Injury or Illness - Check all that apply. For "Fatal",. First Aid treatment i. Employees need to file claims electronically using the.

Fatality - Enter date of death if after date of mishap as mm-dd-yyyy. NOTE: The following categories of mishaps must be reported within. Medical Attention - Inpatient hospitalization means being admitted to the. Cause of Mishap - Identify the event that resulted in the injury or illness.

For property damage or. A Report of Mishap 15 FAM is required whenever a mishap occurs on Department-owned or -leased property, or during the conduct of U. Reporting is required when mishaps result in personal injury or illness, property damage, or environmental contamination.

Sufficient details must be provided to ensure appropriate corrective actions are developed and. Annual Report. This report is designed to document and measure the progress of the safety program.

Mishap reports are reviewed during program assessments. Severity of Injury or Illness Check all that apply. Fatal - Date of Death if after date of mishap - mm-dd-yyyy. Nature of Injury or Illness contusion, laceration, sprain, fracture, muscle strain, etc. Treatment facility name and address if off-site. Describe recommended action s that will prevent the recurrence of a similar mishap in the future,. Featured Tags Bill of Sale U.

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Form DS-1663 "Report of Mishap"






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