AF Form 978 Supervisor's Mishap Report PDF Details

Authority: Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07 and AFI 91-204.

Description of mishap: who, what, when, where, and why; indicate the cause(s); if more space is needed use separate sheet(s) of paper

Disposition of individual: check all that apply to include the number of days

Disclosure: Voluntary, however failure to provide requested information may delay appropriate corrective action

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

Question	Answer
Form Name	AF Form 978 Supervisor's Mishap Report
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min
Edition	20140409
Other names	AF Form 978, DAF Form 978, Air Force Form 978, AF978, Form 978, Supervisor's Mishap Report
Official source	AF Form 978, Supervisor's Mishap Report, Department of the Air Force

How to Fill Out AF Form 978

AF Form 978 at a glance

What it is: AF Form 978 is the Supervisor's Mishap Report.

Who signs: Enter the SUPERVISOR'S NAME, GRADE/RANK and DUTY PHONE, then add the SIGNATURE. The Unit Safety Representative's name, grade/rank, duty phone and signature are entered the same way. The Commander's name, grade/rank, duty phone and signature are entered the same way. For Safety Office use only: Reportable, AFSAS-Number, Mishap Class, Date Mishap Reported to Safety, Non-Reportability Reference and Signature.

AF Form 978 is the Supervisor's Mishap Report.

A filled-in AF Form 978 example: a supervisor reports a slip in a hangar

AF Form 978 example filled out, example: a supervisor reports a slip in a hangar — A supervisor files AF Form 978 for an airman who slipped. The airman slipped in a hangar at 1430 and returned to restricted duty for 3 days. The picture shows the filled form, and every value in it is made up. The airman works Monday through Friday, 0700 to 1500, so SUN and SAT stay empty. The airman returned from deployment 45 days earlier and was deployed 30 days in the last 365 days, and was on duty 7 hours before the mishap. Riley Sample, a coworker, saw the fall. Nothing goes in No Medical Treatment, Admitted to Hospital, Treated and released, Placed on quarters, Place on con leave for or First/Self aid only because the airman only returned to restricted duty.

How to fill out AF Form 978, box by box

Name, grade or rank, unit and job

Enter 1. NAME (Last, First, Middle Initial), 2. GRADE/RANK, 3. AGE and 4. SEX.

Enter 5. UNIT/OFFICE SYMBOL, 6. DAFSC/OCC SERIES, 7. JOB TITLE and 8. DUTY PHONE.

Date, time and duty status of the mishap

Enter 9. DATE OF MISHAP, 11. MISHAP OCCURRED, 12. ON/OFF DUTY and 13. DUTY STATUS.

Enter 10. TIME OF MISHAP in 24hr Format.

Days scheduled to work, shift hours and hours on duty

For 14. Days scheduled to work, check all that apply: Sun, Mon, Tues, Wed, Thurs, Fri and Sat.

Enter 15. WORK SHIFT HOURS in 24hr Format.

Enter 16. HOURS ON DUTY PRIOR TO MISHAP.

Weather, light and deployment

Enter 17. WEATHER CONDITIONS, 18. LIGHT CONDITIONS, 19. # DAYS SINCE LAST DEPLOYMENT/TDY and 20. # DAYS DEPLOYED/TDY IN LAST 365 DAYS.

Location, description and witnesses of the mishap

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

Enter 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).

Enter 23. WITNESSES and 24. WITNESS NAME(S).

Disposition of the individual, type of injury and body parts

For 25. DISPOSITION OF INDIVIDUAL, check all that apply to include the number of days.

Check No Medical Treatment needed or sought.

Check Returned to restricted duty and enter the number of days.

Check Admitted to Hospital and enter the number of days.

Check Treated and released back to regular duty hours.

Check Placed on quarters and enter the number of days.

Check Place on con leave for and enter the number of days.

Check First/Self aid only.

Enter Comments.

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

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

Tox testing and treatment

Enter 28. TOX TESTING and 29. TREATMENT (also, indicate whether medications were prescribed).

Supervisor's name, duty phone and signature

Enter the SUPERVISOR'S NAME, GRADE/RANK and DUTY PHONE, then add the SIGNATURE.

More rules for AF Form 978

Purpose: To assist safety professionals in making identification of individuals and to obtain required personal information to complete mishap reports.

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

Authority: Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07 and AFI 91-204.

This form requires collecting and maintaining information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure.

Disclosure: Voluntary, however failure to provide requested information may delay appropriate corrective action to ensure personal safety and reporting mishap to AFSEC.

The Unit Safety Representative's name, grade/rank, duty phone and signature are entered the same way.

The Commander's name, grade/rank, duty phone and signature are entered the same way.

Enter COMMENTS.

For Safety Office use only: Reportable, AFSAS-Number, Mishap Class, Date Mishap Reported to Safety, Non-Reportability Reference and Signature.

Enter 30. PROPERTY DESCRIPTION (includes serial #/part number) and 31. VEHICLE DESCRIPTION.

Enter the YEAR, MAKE, MODEL and REGISTRATION #.

Enter 32. SPECIFICATIONS and 33. SELECT TYPE/DATE OF TRAINING.

Enter 34. PROPERTY & VEHICLE DAMAGE DESCRIPTION and 35. COST OF REPAIR & MATERIALS COST.

Enter 36. SEATBELT USED, 37. PPE USED, 38. SPEEDING, 39. ALCOHOL INVOLVED and 40. ENTERED IN MUSTT.

Enter 41. MAJCOM unique items.

Common questions about AF Form 978

Is there a penalty?

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

Sources

[1] AF Form 978, Supervisor's Mishap Report, Department of the Air Force (the Official source link on this page).

AF Form 978: Supervisor's Mishap Report