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Fillable Printable Form DS-1663

Fillable Printable Form DS-1663

Form DS-1663

Form DS-1663

VI. SUPERVISOR/POSHO INFORMATION
FILING INSTRUCTIONS
9. Name of Individual - Self Explanatory. Check the "TDY" box if employee
was on a temporary duty assignment when the mishap occurred.
8. Detailed Description of Mishap - Describe in as much detail as possible,
the who, what, where, when, why and how of the mishap. Include relevant
remarks about weather, equipment or tools involved, unsafe conditions,
acts and personal factors and whether other persons may have
contributed to the accident. For environmental mishaps, describe the
failures (equipment or personnel) that led to the release of chemicals or
pollutants.
II. PERSONAL INFORMATION
b. Estimated Days Restricted Duty - The number of days when the
employee could not perform any or all of his or her normal assignment
during all or any part of the workday or shift, because of the injury or illness.
19. WORK-RELATED EMPLOYEE INJURIES ONLY
f. Employee's Shift Start Time - Enter as hh:mm.
e. Employee's Date of Hire - Enter the date as mm-dd-yyyy.
d. Treatment facility name and address (if off-site) - Self Explanatory
c. Name of treating physician/health care provider - Self Explanatory
a. Estimated Calendar Days Lost from work - A count of all calendar days
(consecutive or not), including weekend days and holidays, after, but not
including, the day of injury or illness onset, where the employee would have
worked but could not because of the injury or illness.
Workers' Compensation Claim Filing - Do NOT send CA-1 or CA-2 forms to
OBO/OPS/SHEM. Employees need to file claims electronically using the
Department of Labor's ECOMP system. Contact HR/ER/WLD for additional
information:
NOTE: The following categories of mishaps must be reported within
12 hours as per 15 FAM 964.4-1:
* Injury or occupational illness resulting in a fatality, permanent
total disability or inpatient hospitalization;
* Property damage of $50,000 or more;
* Operations curtailed or shut down for more than 8 hours;
* Any environmental contamination.
* Injuries or occupational illnesses (with lost workdays), involving
three or more employees;
Domestic
Director, DESD (A/OPR/FMS/DESD)
2201 C Street, NW
Washington, DC 20522-6011
or by Fax to 202-647-1873
Overseas
Send the completed form to the Post
Occupational Safety and Health
Officer (POSHO) at your Post. If that's
not possible, scan and email a copy
to OBO/OPS/SHEM at:
1. Agency - Agency of injured individual or agency reporting damaged
property.
6. Time of Mishap - Enter time as hh:mm. Check a.m. or p.m.
3. Organizational Symbol - For domestic mishaps only, provide office
symbol of injured individual or office reporting damaged property.
7. Location of Mishap - Check all the appropriate boxes that apply for
property type and ownership of USG facility or residence. Then briefly
describe the specific location on the property (e.g., warehouse, swimming
pool, cafeteria, office area, bedroom).
5. Date of Mishap - Enter the date of mishap as mm-dd-yyyy. For illnesses
(e.g., cumulative trauma), enter the date of diagnosis or onset of disability,
whichever is earlier.
4. Type of Mishap - Check one or more types that apply to this mishap.
For "Environmental Contamination," see NOTE.
2. Post/City, ST - Provide post name for overseas mishaps, US City and
State for domestic mishaps.
11. Date of Birth - Enter date of injured individual's birth as mm-dd-yyyy.
10. Gender - Self Explanatory.
17. Nature of Injury or Illness - Indicate the type of injury (or property
damage) or illness, such as 2nd degree burn, fracture, abrasion, contusion,
amputation, hearing loss, irritation, cancer, liver disease, contamination,
etc.
18. Body Part(s) Injured - Indicate the body parts(s) injured, such as lower
arm, ankle, ribs, neck, head, eye, hearing, liver, respiratory tract, etc.
(Leave blank for property damage mishaps).
14. Fatality - Enter date of death if after date of mishap as mm-dd-yyyy.
13. Severity of Injury or Illness - Check all that apply. For "Fatal",
"Permanent Disability", see NOTE. For "Lost time/Restricted Duty, enter
the number of days in block 17. "Medical Attention Other than First Aid"
are mishaps that do NOT result in lost time from work, but where medical
treatment is administered by a physician or registered professional
personnel under the orders of a physician. First Aid treatment (i.e.,
one-time treatment of minor scratches, cuts, burns, splinters and so forth)
does not ordinarily require medical care, even if administered by a
physician or registered professional.
15. Medical Attention - Inpatient hospitalization means being admitted to the
hospital for at least one overnight stay resulting from the injury/illness. For
"Emergency Room" medical care, check for any instances where the
patient used emergency room services.
16. Cause of Mishap - Identify the event that resulted in the injury or illness
(such as falling from, struck by, lifting, inhaling) and the object or source
involved (such as ladder, tool, chemical). For property damage or
environmental contamination, provide the event and source leading to the
damage/contamination.
Signatures - The POSHO must review and sign off on the DS-1663.
22. Property Status - Check if property is government owned.
23. What Corrective Action Has Been or Will Be Implemented - Describe
action(s) to be taken that will prevent the recurrence of similar mishaps in the
future. Indicate whether actions have been implemented, or estimated date of
when actions will be implemented.
12. Category and Job/Activity - For employees, check one personnel
category and provide the injured employee's job title or a brief job
description. (FS - Foreign Service, GS - General Service, FSN - Foreign
Service National, EFM - Eligible Family Member, PSC - Personal Services
Contractor, CON - Contractor. For Other - enter brief description (e.g.,
family member, local national)). Check the "Post-Managed Contractor?" box
if the contractor is being managed by Post personnel, versus OBO
personnel on an OBO-managed project.
20.Estimated Amount of Property Damage- Self Explanatory.
Leave blank for injury/illness mishaps.
REPORT OF MISHAP INSTRUCTIONS
AUTHORITY: The Occupational Safety and Health Act of 1970 (29 U.S.C. 657, 673); Secretary of Labor's Order No. 12-71 (36 FR 8754), 8-76 (441 FR 25059),
or 9-83 (48 FT 35736) and Code of Federal Regulations, Occupational Safety and Health Administration, Labor (29 1904, 1-22).
The DS-1663, Report of Mishap (15 FAM 963) is required whenever a mishap occurs on Department owned or leased property or during the conduct of U.S.
Government business. Reporting is required when mishaps result in personal injury (excluding a minor injury requiring to only first aid treatment), property
damage in excess of $1,000 or any environmental contamination.
PURPOSE: The principal purpose of the Report of Mishap is to inform safety and health officials of all serious occupational injuries, illnesses, and environmental
contamination incidents. Sufficient details must be provided to help prevent future occurrences. It is also used to insure that supervisors are aware of their
safety/health responsibilities.
ROUTINE USES: These reports are used to provide statistical information to the Department of Labor in the Department's Safety and Occupational Health
Annual Report. This report is designed to document and measure the progress of the safety program. Mishap reports are reviewed during program
assessments and to focus training/assistance efforts on the information contained therein.
PRIVACY ACT STATEMENT
DS-1663
07-2017
Instruction Page 1 of 1
For mishaps causing injury or illness to more than one individual, complete and attach a DS-1663
(with only sections 1-19 completed) for each additional individual.
I. MISHAP INFORMATION
III. INJURY/ILLNESS INFORMATION
V. CORRECTIVE ACTION
21. Type of Property- Such as building, residence, GOV, POV, personal
property, security barrier, etc.
IV. PROPERTY DAMAGE INFORMATION
Workers' Compensation Program
SHEM-MRSAdmin@state.gov
21. Type of Property
23. Describe recommended action(s) that will prevent the recurrence of a similar mishap in the future,
and whether or when these actions have been implemented.
16. Cause of Mishap
17. Nature of Injury or Illness (contusion, laceration, sprain, fracture, muscle strain, etc.)
18. Body Part(s) Injured
19. WORK-RELATED EMPLOYEE INJURIES ONLY:
a. Calendar Days Lost
c. Name of treating physician/health care provider
d. Treatment facility name and address (if off-site)
e. Employee's Date of Hire (mm-dd-yyyy)
f. Employee's Shift Start Time (hh:mm)
b. Days Restricted Duty
20. Est Amount of Property Damage
22. Property Status
USG owned
IV. PROPERTY DAMAGE INFORMATION
V. CORRECTIVE ACTION
VI. SUPERVISOR/POSHO INFORMATION
Supervisor's Signature
Supervisor's Name
POSHO's Name and Title
Date (mm-dd-yyyy)
POSHO's SignatureDate (mm-dd-yyyy)
9. Name of Individual (Last, First, MI.)
10. Gender (Check one)
MaleFemale
11. Date of Birth (mm-dd-yyyy)
12. Category (Check one)
Job/Activity
FS
GS
FSN
EFM
PSC
CON
Other
TDY
II. PERSONAL INFORMATION
8. Detailed Description of Mishap/Property Damage (please attach Form DS-1664 if Motor Vehicle)
4. Type of Mishap (Check all that apply)
Property Damage
Environmental Contamination
Illness/Injury
1. Agency
2. Post/City, State
3. Organizational Symbol
5. Date of Mishap (mm-dd-yyyy)6. Time of Mishap (hh:mm)
p.m.
a.m.
13. Severity of Injury or Illness (Check all that apply)
Fatal
Permanent
Disability
Lost Time/
Restricted Duty
Medical Attention
(Other than First Aid)
DS-1663
07-2017
REPORT OF MISHAP
p.m.
a.m.
7. Location of Mishap (Check all that apply)
Specific Location
a. Type:
b. Ownership:
Other
USG Facility
Gov. Owned/Capital LeaseOperating Lease
USG Residence
COMPLETE THIS FORM TO REPORT ALL MISHAPS RESULTING IN INJURIES, INCLUDING INJURIES FROM OFFICIAL VEHICLE MISHAPS, ILLNESSES, OR ENVIRONMENTAL CONTAMINATION
14. Fatal - Date of Death (if after date of mishap - mm-dd-yyyy)
15. Medical Attention
Inpatient Hospitalization
Emergency Room
U.S. Department of State
I. MISHAP INFORMATION
III. INJURY/ILLNESS INFORMATION
LQA
First Aid
Post-managed Contractor?
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