If a motor vehicle mishap results in injury or death to any employee, including tenant agency employees, family member, contractor, or local national, a DS- Reporting Instructions Submit completed DS and DS if applicable to The DS Overseas Motor Vehicle Mishap Report 15 FAM is required. Injury information should be included on Form DS (use a separate form for 30 days of when the mishap occurs: (1) A Form DS, Report of Mishap.

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All increased-risk nonoffice work operations and areas will be inspected by one or more qualified safety and occupational health professional s at least once a year.

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

Occupational health or industrial hygiene studies, surveys, etc. Safety assessments will be done by or under the supervision of a certified safety professional CSP.

In areas where more specialized expertise is required, a person possessing such expertise may be requested to accompany the safety and health professional on such inspections. In addition to requirements in paragraph a of this section, the POSHO will inspect all work areas annually and increased-risk work areas or operations 15 fam Page 1 of Supervisors are responsible for regular hazard inspections of their workplaces on a daily or weekly basis, depending on the nature of their work.

In addition to inspections conducted by personnel in paragraph b of this section, construction engineers licensed in the civil, mechanical, and electrical disciplines must inspect construction-site activities involving OBO-administered contracts.

Miishap are responsible for regular hazard inspections of their workplaces on a daily mkshap weekly basis, depending on the nature of the work. An increased risk or high-risk activity is a workplace or environment with a high potential for mishaps or occupational illnesses. Included are activities involving, but not limited to: High-risk activities include all public works facilities, activities, and shops. Inspections will include a comprehensive hazard assessment addressing the potential for losses and exposures to fire, safety, health, and environmental hazards.

A complete risk analysis of each work operation will be done that includes environmental factors, training needs, materials used, hazardous or toxic chemicals used, control systems, protective equipment used, and any other relevant factors. Quantification of potentially harmful exposures to hazardous or toxic chemicals, materials, noise, lead, asbestos, radiation, biological materials, or other hazards must be accomplished by or under the supervision of industrial hygienists certified in comprehensive aspects of industrial hygiene.

Occupational safety and health personnel are authorized to enter unannounced and without delay for the purpose of inspecting any da-1663, installation, facility, construction site, or area where work is being performed by employees misap the Department of State or other agencies. Inspecting personnel are authorized to question, privately, any employee, supervisor, or official in charge of the establishment concerning safety and occupational health conditions and concerns.

Inspection personnel on OBO construction projects will provide written reports of findings and recommendations to the OBO project director for action. Inspection personnel are not authorized to direct OBO contractors to take action that may result in changes in contract requirements or increased costs to OBO. In cases where immediate danger exists, inspection personnel will immediately inform the OBO project director in charge, orally and then in writing, of the potential danger and the actions required to correct the problem.

The project director will take appropriate action to ensure that work is stopped until the imminent hazard can be abated. The safety and occupational health personnel conducting inspections will give officials in charge of the facility and employee representatives an opportunity to accompany them during the physical inspection of the workplace. The inspector will obtain the appropriate security clearances to inspect areas or 15 fam Page 2 of All inspection findings, except those corrected at the time of the inspection, will be documented in an inspection report that is officially conveyed to the manager responsible for the inspected work area s.

The report must specify time frames for compliance. The individual conducting the inspection will forward a copy of the report to members of the safety committee and the employee representative, if any.

Also, a copy electronic or written will be maintained by the POSHO for a period of 5 years after the inspection. Immediate action will be taken to eliminate the hazard as soon as it is concluded that, on the basis of an inspection, a risk exists that could reasonably be expected to cause serious physical harm or illness. The inspector should inform the official in charge of the workplace and the designated POSHO, orally and then in writing, of the potential danger and the actions required to correct the problem.


When an imminent danger is identified as described in paragraph b of this section, a Form DS, Notice of Alleged Safety or Health Hazards, must be completed and immediately posted in the affected work area until the hazard is permanently abated. It should be written in English, as well as the hostcountry language if non-english speaking employees work in the area affected. The narrative should describe in detail the nature and degree of seriousness of the hazard, remedial measures to be taken until the hazard is abated, and a reasonable time for abatement or correction.

The request can be made orally, but must be followed with a written request. Upon receipt of such a request, the POSHO will direct an investigation and respond to the requester within 24 hours for reports of imminent danger conditions; within 3 working days for potentially serious conditions; and within 14 working days for other than serious conditions.

If the condition constitutes a violation of Department of State 15 fam Page 3 of This section lists procedures for investigating, analyzing, and reporting mishaps that occur abroad. A mishap is any unplanned, unexpected, or undesirable event causing injury, disease or illness, death, material loss or property damage, or incident causing environmental contamination, including improper pesticide application and leaking underground or above-ground storage tanks.

The term mishap is used instead of accident or occupational illness and includes motor vehicle collisions. Mishaps that occur on Department of State-owned or -leased premises, or during the conduct of U. Government business, including motor vehicle mishaps, will be immediately investigated and reported.

Reportable motor vehicle mishaps include any mishap while operating a U. Government-owned, -rented, or -leased vehicle or a private vehicle used for official business. There are special reporting requirements for Class A and Class B mishaps, as well as any environmental contamination mishap. A mishap investigation and analysis board MIAB is appointed to conduct an analysis and investigation for the sole purpose of preventing future mishaps.

The board may be comprised of several members or a single individual, depending on the circumstances of the mishap. The classification determines the level of investigation required.


Mishaps must be classified into one of the following three categories as soon as a reasonable estimate of total cost is made: Jishap mishap investigation and analysis board will be appointed as soon as practical. Class A and Class B board memberships will vary according to gravity and type of mishap. Whenever possible, board members should have appropriate experience and technical backgrounds. For mishaps involving death or illness, consideration should be given to including a medical doctor.

Mishap boards involving fire should include a certified fire investigator. However, the POSHO can draw on other individuals having specialized expertise needed to effectively investigate and analyze the mishap. Posts will notify SHEM about all Class A and Class B mishaps, or any environmental contamination incident including improper pesticide application within 12 hours.

Government driver involved in the mishap. Injury information should be included on Form DS use a separate form for each injured person. Nonvehicular property damage from a motor vehicle mishap must be reported on Form DS Property damage or environmental contamination from other types of mishaps must be reported on Form DS c.

Post mishap boards will 15 fam Page 6 of Class A and Class Miahap mishap reports are signed by all board members and include five main sections: This section should document only factual data that relates to the mishap and the personnel involved. Include a chronological history of events leading up to the mishap, information on specific injuries and property damage, policies and procedures relevant to the mishap, records and other appropriate es-1663 2 Analysis and conclusions: This section is an analysis of the factual information and conclusions drawn from that information, and establishes the contributing factors of the mishaps; 3 Recommendations: State corrective actions to be implemented to prevent a recurrence based on key contributing factors and conclusions drawn in the previous section; 4 Actions taken: List the actions ss-1663 and their completion dates or projected completion datesand provide an implementation plan for continuing actions; and 5 Appendices: Attach relevant supporting documentation.

Examples may include the following: In addition to the requirements already stated, the POSHO will maintain copies of all mishap reports and forms for 5 years. With fire-related mishaps that involve illness, injury, or death, the SHEM Director will coordinate 15 fam Page 7 of Recommendations usually relate to organizational and operational changes needed to minimize the occurrence of similar mishaps. Class A mishap reports will be distributed only on a need-to-know basis, in order to preserve the independence and integrity of the investigation process.


None of the information developed during the investigation or included in the report will be used to justify disciplinary measures or to take legal action against employees involved in the mishap. The Ds-663 will immediately investigate all Class C mishaps, including motor vehicle mishaps, and ensure that appropriate corrective actions are implemented. Property damage from a mihap vehicle accident will be reported on Form DS Property damage or environmental contamination from other types of mishaps will be reported on Form DS Other post fire reporting requirements, not related to Class A or B mishaps, are contained in 15 FAM The POSHO will ensure that management officials are provided with an orientation and other learning experiences that enable them to meet their safety and occupational health responsibilities.

The orientation should include coverage of section of the Foreign Service Act ofExecutive Order 15 fam Page 8 of The POSHO will ensure that supervisors are provided occupational safety and health training that includes supervisory responsibilities for providing and maintaining safe working conditions for employees and the administration of a proper safety and occupational health program.

Supervisors will also receive training in recognizing and abating hazards specific to their workplaces.

Each post will provide training for POSHOs in appropriate standards and in the use of equipment and procedures that will enable them to conduct competent safety and health inspections. They should be trained on how to propose methods of hazard abatement to post officials and how to properly document inspection findings.

All employees will be provided with information needed to perform their jobs in a safe manner. The POSHO will ensure that a safety and occupational health orientation is provided for all new employees, and that specialized SHEM training related to the work performed by particular employees clerical, printing, welding, crane operation, chemical and material handling, computer operation, etc.

Refresher training must be conducted at least annually. In addition, fire-safety training, including fire drills, will be conducted. POSHOs will maintain training records documenting names of people trained, job titles, positions, and types of training provided, including specific subjects and dates of training.

Frequently, there are potential safety and occupational health or environmental problems associated with new initiatives or projects conducted by the post new building construction; building renovation; new or changes to operational procedures; change in materials used in an operation, such as a new chemical or piece of equipment; new use of existing materials, etc.

Early identification of such potential hazards makes it possible to eliminate or control them with nominal costs.

Fillable Form Ds – Report Of Mishap – U.s. Department Of State printable pdf download

Once uncontrolled hazards have been introduced, costs for retrofit and abatement are incurred and are generally much greater than those for eliminating or controlling the hazard in the planning or development stage.

The POSHO will participate in all post planning activities for new projects and initiatives, whether they are sponsored internally or externally. If necessary, the POSHO will provide the responsible manager with specific written documentation of the potential hazards involved and actions required eliminating or controlling those hazards.

Assessment documentation should be provided to the manager even if no hazards are discovered. A copy of safety and health planning analyses should be maintained by the POSHO for 3 years after the project is completed. Posts will develop and publish specific procedures, requirements, and responsibilities for implementing requirements of 15 FAM This document should be reissued by the chief of mission or by the designated 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. This assessment is to be submitted each year by December 31, along with SHEM program goals and objectives for the coming year. Records provide employers and OSHA with statistical data to determine where emphasis should be.

Respond to each question below by circling “” or “” to indicate “yes” or “no. George Mason University Prepared by: To update the Department of. May 14, Model Policy Revised: