Supervisor's Mishap Report of Illness/Injury
Mishaps that result in occupational injuries, illnesses or deaths to personnel degrade operational readiness and increase operation costs. Investigations of mishaps to identify causes and preventive actions, as well as establishing accurate record keeping, are essential to the success of the Navy Occupational Safety and Health (NAVOSH) Program. Mishap investigations aimed at determining how and why the event occurred are necessary to prevent future occurrence of similar events. Accurate records are necessary to establish trends, conduct analyses, and to assess the effectiveness of the overall NAVOSH Program.
The regulatory driver for reporting an Injury/Illness is OPNAVINST 5100.23 (series), chapter 14 and OPNAVINST 5102.1D.
To comply, employees and supervisors shall follow the requirements below:
EMPLOYEES: Employees shall report immediately to their supervisor any occupational injury or illness.
SUPERVISORS: The Supervisor shall complete their portion of the Dispensary Permit and provide it to all civilians who need treatment. Employees shall not visit the clinic without a completed permit, unless emergency medical care is necessary.
The Naval Safety Center has revised mishap-reporting requirements to include all injuries and illnesses, including military off-duty and motor vehicle injuries, which prevent personnel from performing scheduled duty beyond the day or shift of injury or onset of illness. CNIC requires that mishap reports for CNRMA Commands be entered into the Enterprise Safety Application Management System (ESAMS) , which is used to forward them to the Naval Safety Center within 48 hours from the date of injury. This process will update the Naval Safety Center's Web Based Safety System (WESS) Questions should be directed to your Safety Office. Commands not supported by the Safety Office should follow procedures from their chain of command.
If you do not have access to ESAMS, please fill out the blank Mishap Report. This blank Mishap Report is also useful in organizing your mishap data prior to logging the mishap into ESAMS (it follows the ESAMS IIRTS Report format).
The supervisor shall submit through ESAMS a report within 48 hours of an injury or illness.
Recommend safety mishap investigator use the applicable WESS worksheet(s) available on the Naval Safety Center website to help ensure all the necessary information is obtained before entering data in ESAMS and/or WESS. Worksheets are available for the following type mishaps:
Electric Shock (Submarines)
Property Damage and Injury
Personal Injury While on Duty
USMC HRST Property Damage
USMC HRST Training Personnel Injury
and Property Damage
USMC HRST Training Personnel Injury
Ordnance Mishap with:
Injuries and Property Damage
Flying / Flying Club
Hunting, Shooting, Fireworks, Gun Handling
USMC Personnel Injury
USMC Personnel Injury and Property Damage
USMC TRNG Property Damage Only
Government Motor Vehicle and Property Damage
Motorcycle (street and off-road)
Private Motor Vehicle (4-wheel, pedestrian, bicyclist)
Navy High Risk:
Navy High Risk Personnel Injury and Property Damage Templete
Navy High Risk Personnel Injury Template
Navy High Risk Property Damage Template
Parachute Mishap Worksheet With Injuries
Parachute Malfunction Without Injuries
Shore Ground Injury - Navy
Shore Ground Injury - USMC
Click here for Motor Vehicle Accent Reporting involving a government motor vehicle.
Workers Compensation Forms, e.g., CA-1, CA-2, etc. should be delivered to the Human Resources Office Norfolk, Employee Services. Questions should be directed to (757) 444-6253, fax: (757) 444-8656. For details on The Federal Employees' Compensation Act (FECA), see the Injury Compensation Program in the HRO Norfolk Personnel Manual. Note that medical documentation is required for all lost workdays and all ORIGINAL Workers Compensation Forms must be sent to HRO.
Medical Referral Form- Employees shall report immediately to their supervisor any occupational injury or illness. The supervisor shall furnish OPNAV 5100/9, Medical Referral or equivalent to civilian employees who need treatment. Activities shall not permit employees to visit the Navy Medical Treatment Facility (MTF) without having obtained the form, except where necessary to avoid delay in treatment to the detriment of an employee. In this case, activities may complete the form after the patient has been removed to the MTF.