Form 978 PDF Details

In the realm of military operations, the preservation of personnel safety and the meticulous documentation of mishaps are paramount. The Supervisor's Mishap Report, delineated by the form number 978, serves as a critical instrument in this endeavor, underpinned by several authoritative sources including Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07, and AFI 91-204. This form not only mandates the collection of comprehensive data regarding any mishap—ranging from personal information of the individuals involved to the minute details of the incident itself—but also establishes a protocol for identifying the causes behind such incidents to prevent future occurrences. Furthermore, it caters to the requirements stipulated by the Privacy Act of 1974, ensuring that the collected information remains protected against unauthorized access and disclosure. Its utility extends beyond mere documentation; it aids in the preparation of statistical and historical reports, supports the identification of unsafe conditions, and facilitates the accountability and corrective actions within the Department of the Air Force. The meticulous completion of this form is voluntary, yet essential for the timely and effective response to mishaps, highlighting its critical role in maintaining safety and ensuring a continuous evaluation of occupational hazards. The form’s structured approach to data collection—encompassing everything from the mishap's environmental conditions to the specifics of any property damage—underscores the comprehensive measures taken to safeguard both personnel and resources.

QuestionAnswer
Form NameForm 978
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaf 978 form, af 978 mishap report, af form 978 supervisor's mishap report, air force form 978

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SUPERVISOR'S MISHAP REPORT

Authority: Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07 and AFI 91-204. Privacy Act: This form requires collecting and maintaining

information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure. Purpose: To assist safety professionals in making

identification of individuals and to obtain required personal information to complete mishap reports. Routine Use: Used to (a) Establish the severity of injury/illness and to ensure proper reporting accountability within the Department of the Air Force; (b) Identify causes of illness/injuries so supervisors and functional managers can take appropriate action to eliminate or control unsafe and unhealthy conditions; (c) Prepare statistical and historical reports as required by Executive Order 12196 and Department of Defense; (d) Provide documentation for cumulative summation of treatment causes. Disclosure: Voluntary, however failure to provide requested information may delay appropriate corrective action to ensure personal safety and reporting mishap to AFSEC.

MISHAP DATA INFORMATION

1. NAME (Last, First, Middle Initial)

2. GRADE/RANK

3. AGE

4. SEX

5. UNIT/OFFICE SYMBOL

6. DAFSC/OCC SERIES

7. JOB TITLE

8. DUTY PHONE

9. DATE OF MISHAP

10.TIME OF MISHAP (24hr Format)

11. MISHAP OCCURRED

12. ON/OFF DUTY

13. DUTY STATUS

 

 

14. DAYS SCHEDULED TO WORK (check all that apply)

 

 

 

15. WORK SHIFT HOURS (24hr Format)

 

16. HOURS ON DUTY PRIOR TO MISHAP

 

 

SUN

MON

TUES

WED

THURS

 

FRI

SAT

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. WEATHER CONDITIONS

 

18. LIGHT CONDITIONS

 

19. # DAYS SINCE LAST DEPLOYMENT/TDY

 

20. # DAYS DEPLOYED/TDY IN LAST 365 DAYS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.LOCATION OF MISHAP SITE (bldg. #, room, street name, intersection, parking lot, home, work, etc.)

22.DESCRIPTION OF MISHAP (who, what, when, where, and why; indicate the cause (s); if more space is needed use separate sheet (s) of paper)

23. WITNESSES

24. WITNESS NAME(S)

25. DISPOSITION OF INDIVIDUAL (check all that apply to include the number of days)

No Medical Treatment needed or sought

 

 

 

 

Returned to restricted duty

 

number of days

 

 

 

 

 

Admitted to Hospital

 

number of days

 

 

 

Treated and released back to regular duty hours

 

 

Placed on quarters

 

number of days

 

 

 

 

 

Place on con leave for

 

number of days

 

 

First/Self aid only

 

Comments

 

 

 

 

 

 

 

26. TYPE OF INJURY/INJURIES (i.e., bruise, fracture, cut, sprain, etc.)

27. BODY PART(S) INJURED (i.e., lower back, head, right knee, etc.)

AF FORM 978 20140409

The information herein is For Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. The unauthorized disclosure or

misuse of this personal information may result in criminal and/or civil penalties.

28. TOX TESTING

29. TREATMENT (also, indicate whether medications were prescribed)

PROPERTY DAMAGE

30. PROPERTY DESCRIPTION (includes serial #/part number)

31. VEHICLE DESCRIPTION

YEAR

MAKE

MODEL

REGISTRATION #

32. SPECIFICATIONS

33. SELECT TYPE/DATE OF TRAINING

34. PROPERTY & VEHICLE DAMAGE DESCRIPTION

35.COST OF REPAIR & MATERIALS COST

36. SEATBELT USED

37. PPE USED

38. SPEEDING

39. ALCOHOL INVOLVED

40. ENTERED IN MUSTT

41. MAJCOM unique items

SUPERVISOR, UNIT SAFETY REPRESENTATIVE, COMMANDER AND SAFETY OFFICE REVIEW AND SIGNATURE

SUPERVISOR'S NAME, GRADE/RANK

DUTY PHONE

SIGNATURE

Click to sign

UNIT SAFETY REPRESENTATIVE'S NAME, GRADE/RANK

DUTY PHONE

SIGNATURE

Click to sign

COMMANDER'S NAME, GRADE/RANK

DUTY PHONE

SIGNATURE

Click to sign

COMMENTS

FOR SAFETY OFFICE USE ONLY

REPORTABLE

AFSAS-NUMBER

MISHAP CLASS

DATE MISHAP REPORTED TO SAFETY

NON-REPORTABILITY REFERENCE

SIGNATURE

Click to sign

AF FORM 978 20140409

The information here in is For Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. The unauthorized disclosure or

misuse of this personal information may result in criminal and/or civil penalties.

How to Edit Form 978 Online for Free

We have used the efforts of our best programmers to build the PDF editor you can work with. The application will enable you to complete the af 978 mishap report document without any difficulty and don’t waste your time. What you need to do is comply with these particular simple recommendations.

Step 1: The following web page includes an orange button saying "Get Form Now". Hit it.

Step 2: At the moment, you can start editing the af 978 mishap report. The multifunctional toolbar is at your disposal - insert, eliminate, modify, highlight, and perform other sorts of commands with the content material in the form.

In order to prepare the af 978 mishap report PDF, provide the details for each of the parts:

stage 1 to completing af form 978 supervisor's mishap report

Fill out the WITNESSES, WITNESS NAMES, DISPOSITION OF INDIVIDUAL check, TYPE OF INJURYINJURIES ie bruise, No Medical Treatment needed or, Returned to restricted duty, number of days, Admitted to Hospital, number of days, Treated and released back to, Placed on quarters, number of days, number of days, BODY PARTS INJURED ie lower back, and Place on con leave for section with the information asked by the program.

part 2 to finishing af form 978 supervisor's mishap report

Write the main data in TOX TESTING, TREATMENT also indicate whether, PROPERTY DESCRIPTION includes, VEHICLE DESCRIPTION, PROPERTY DAMAGE, YEAR, MODEL, MAKE, REGISTRATION, SPECIFICATIONS, SELECT TYPEDATE OF TRAINING, PROPERTY VEHICLE DAMAGE, COST OF REPAIR MATERIALS COST, SEATBELT USED, and PPE USED section.

part 3 to filling out af form 978 supervisor's mishap report

The COST OF REPAIR MATERIALS COST, MAJCOM unique items, SUPERVISOR UNIT SAFETY, SUPERVISORS NAME GRADERANK, DUTY PHONE, SIGNATURE, UNIT SAFETY REPRESENTATIVES NAME, DUTY PHONE, SIGNATURE, COMMANDERS NAME GRADERANK, DUTY PHONE, SIGNATURE, COMMENTS, Click to sign, and Click to sign area will be your place to indicate the rights and obligations of each side.

part 4 to completing af form 978 supervisor's mishap report

Finalize by looking at all these areas and filling them out correspondingly: NONREPORTABILITY REFERENCE, SIGNATURE, Click to sign, AF FORM, and The information here in is For.

af form 978 supervisor's mishap report NONREPORTABILITY REFERENCE, SIGNATURE, Click to sign, AF FORM, and The information here in is For blanks to fill

Step 3: Hit "Done". It's now possible to transfer your PDF document.

Step 4: In order to prevent probable future issues, take the time to possess minimally two or three copies of each separate document.

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