J- -07-07 Contractor Incident Report System Form
Updated
A PDF document (298 KB) attached to Base Operations Support Services For NSA Annapolis and US Naval Academy, Annapolis, Maryland, from the Department of the Navy.
File name: J-0200000-07-07 Contractor Incident Report System (CIRS) Form.pdf
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ATTACHMENT J-0200000-07-07
Contractor Incident Report System (CIRS) Form
Initial Report Follow-up Report Final Report
Date
/
_/
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1. Contract Information
Prime Contractor:
Incident Information
Cage Code:
Contract Number:
Installation of Incident:
Task Order #:
Contracting Activity/ROICC Office:
Contractor Contact Information
Name (Last, First):
Phone #:
Email Address:
Date Notified:
2. Incident Type
(Please Check/Bold All That Apply)
Assault/Violent Act
Extreme Environmental Exposure
Man over the side (No water entry)
Diving
Falls, slip, trip, or bodily exertion
Man Overboard - Water Entry
Electrical Shock/Burns
Fires - All Types
Material Handling Equipment
Equipment
Installation/Repair
Hazardous Material (any type)
Ordnance-Related (Explosive)
Explosion, Non-Ordnance
Industrial
(Select Additional Below)
Vehicle (Government or Private)
Industrial Incident Additional Information
(Please Check/Bold All That Apply)
Confined Space
Hand and Power Tools
Work Platforms and Scaffolding
Demolition/Renovation
Rigging
Underground Construction, Shafts, and
Caissons
Trenching/Entrapment
Cranes and Hoisting Equipment
Concrete, Masonry, Steel Erection and
Residential Construction
Traffic Control
Floating Plant and Marine Activities
Tree Maintenance and Removal
Welding and Cutting
Pressurized Equipment and System
Airfield and Aircraft Operations
Control of Hazardous Energy
Fall Protection
3. General Information
Date of Accident:
Incident Information
Time of Accident:
Describe the accident in detail in your words: (Use the back of page if you need additional space)
Exact Location of Accident:
Were Hazardous Material(s) Involved
Yes
No
If Yes, Explain What Hazardous Materials Were Involved and Why:
Who Provided Clean-up?
Onsite
Base
Public
Activity of the injured person at the time of incident:
Personal Protective Equipment: (Check/Bold Response)
List PPE Used:
Available and used
Available and not used
Not related to Mishap
Wrong PPE for job
Not Required
4. Fully Explain What Allowed or Caused the Incident:
Incident Information
Direct Cause:
Indirect Cause:
Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description)
Additional Action Taken: (Please Include a Begin Date and Est. End Date in Description) (Use the back of page if you need additional space)
5. Contributing Factors:
Was Visibility Restricted?
Yes
Unit of Measure (Check/Bold):
No
Feet
Distance Visibility was restricted:
Yards
Meters
Miles
Nautical Miles
Visibility Restricted By: (Check/Bold all that apply)
Fog
Smoke
Rain
Sleet
Snow
Mist
Dust
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