Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Demographic Data

  • Battalion

  • Company / Battery

  • Mission

Safety Culture

  • Commanders have a Safety motto, vision, or goal for this exercise?

  • Soldiers know the Safety motto, vision, or goal?

  • DD Form 2977's are complete and signed by the appropriate authority for the exercise / mission?

  • Safety is addressed in the Operations Order and all subsequent orders?

  • The mishap reporting process is clearly defined and displayed prominently?

  • All mishaps, injuries, and near miss incidents are being reported and investigated

  • Command involvement positively effected the Safety culture with defined Safety objectives and provided adequate resources

  • Appointed Unit Safety Officers (USO) are trained in their responsibilities and communicated hazards to Command teams.

  • Commanders hold individuals accountable to Safety standards and assure realistic timelines that provide for sufficient mission planning. (20/80 time rule)

Safety Leadership

  • Commanders have completed the Leaders Safety & Occupational Health Course (LSC)?

  • Command teams have Safety awards and defined criteria for nominations and approvals?

  • Commanders have approved Pre-Mishap Plans, Emergency Action Plans, Mishap Logs, Hazard Logs, and similar documents?

  • Commanders have appointed qualified Soldiers to perform USO duties?

  • USOs are afforded time and resources to perform Safety functions? USOs are not assigned any other additional duties that limits availability for Safety concerns.

  • USOs conduct and document daily walk-around inspections?

  • Safety recommendations are implemented in a timely manner?

  • Based on interviews with Commanders and leaders, what were the top hazard prevention priorities for the mission / exercise?

Safety Behaviors

  • Are Soldiers using Personal Protective Equipment (PPE) and is there enough PPE available for all Soldiers?

  • Soldiers are not taking shortcuts or violating Safety standards?

  • Soldiers are adequately supervised and on-the-spot Safety corrections are being made?

  • Soldiers know who to report to and how to report a mishap, injury, or near miss.

  • Are Soldiers performing unsafe acts?

  • Soldiers have a sense of ownership in the Safety program.

  • Based on observations, Safety Behavior errors are related to which type(s) of failure?

Safety Training

  • Are hazards identified and controls implemented for collective METL tasks?

  • Is the unit tracking any type of Safety metrics?

  • Are controls in place for remedial or refresher training?

  • Are equipment operators properly licensed?

  • Was the Pre-Mishap Plan and Inclement Weather Plan rehearsed?

  • USOs meet regularly with planners to discuss upcoming training and/or missions?

  • Based on observations, is there an Individual or Collective Safety training gap?

  • If yes, explain the shortcoming.

Safety Statistics

  • Available Strength

  • On-Duty Mishaps

  • On-Duty Injuries

  • Near Miss

  • Mishap Rate

  • Injury Rate

  • Mishap / Injury Log available?

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