J- -04 thru 06

ATTACHMENT J-0200000-05-1

Additional Witnesses:

(List any additional witnesses on a separate sheet and attach.)

Contractor Significant Incident Report (CSIR)

DISTRIBUTION: DoW COMMUNITY ONLY

Yes

No

ATTACHMENT J-0200000-05-1

CONTRACTOR SIGNIFICANT INCIDENT REPORT (CSIR) INSTRUCTIONS

Complete Sections Appropriate to Incident (Rev. 06/02).

NOTE: THE ATTACHED CSIR FORM IS TO BE USED BY CONTRACTORS TO RECORD THE

RESULTS OF THEIR ACCIDENT/INCIDENTS INVESTIGATIONS AND SHALL BE PROVIDED TO THE

CONTRACTING OFFICER WITHIN THE REQUIRED TIMEFRAMES.
GENERAL. Complete a separate report for each person who was injured in the accident. A report needs to be completed for all OSHA recordable accidents, property damage in excess of $2000.00 (This amount is for record purposes only. GOV is not required to enter property damage reports into FAIR database if it is less than $10,000.00.), WHE accidents, or near miss/high visibility mishaps. Please type or print legibly. Appropriate items shall be marked with an “X” in box(es), non-applicable sections shall be marked “N/A”. If additional space is needed, provide the information on a separate sheet of paper and attach to the completed form. Mark the report:
INITIAL – If this form is being used as initial notification of a Fatality or High Visibility Mishap. The initial form is due within 4 hours of a serious accident. A form marked ‘Follow-up’ or ‘Final’ is required within 5 days. FOLLOW-UP – If you are providing additional information on a report previously submitted. FINAL – If you are providing a completed report and expect no changes.

SECTION 1 – GENERAL INFORMATION

CONTRACTING ACTIVITY/ROICC OFFICE - Enter the name and address of the Contracting Office administering the contract under which the mishap took place (e.g. ROICC MCBH, ROICC NORFOLK, PWC GUAM, etc.). ACCIDENT CLASSIFICATION - INJURY/ILLNESS/FATALITY/PROPERTY DAMAGE/-PROCEDURAL ISSUES/ENVIRONMENTAL/LESSONS LEARNED/OTHER – Mark the appropriate block(s) if the incident resulted in any of these conditions.
INVOLVING - If the mishap involved any of the conditions listed under “Involving” mark the appropriate box(es). Specific questions associated with each of these conditions are available from the Contracting Officer to assist you in your investigation. When these questions are used they shall be attached as part of this report.

SECTION 2 - PERSONAL INFORMATION

NAME - Enter last name, first name, middle initial of person involved. AGE - Enter age.
SEX - Enter M for Male and F for Female.