USR Quarterly Briefing

• Unit Safety Representative (USR) Quarterly Report to Unit Commander

• Squadron

• Conducted on

  Date

• USR Briefing

• Location
  Address

• Supervisor

Unit Mishap Experience

• 1. Mishap Event

• Casual Factors

• Corrective Actions Taken

• Comments (Loss Work Days, Restricted Duty, Etc.)

• 2. Mishap Event

• Causal Factors

• Corrective Actions Taken

• Comments (Loss Work Days, Restricted Duty, Etc.)

• 3. Mishap Event

• Causal Factors

• Corrective Actions Taken

• Comments (Loss Work Days, Restricted Duty, Etc.)

Unit Safety Inspection Experience

• Building Number

• Significant Findings

• Corrective Actions Taken

• Comments

• Building Number

• Significant Findings

• Corrective Actions

• Comments

• Building Number

• Significant Findings

• Corrective Actions

• Comments

• Building Number

• Significant Findings

• Corrective Actions

• Comments

  Yes

  No

  N/A

• Building Number

• Significant Findings

• Corrective Actions

• Comments

• Building Number

• Significant Findings

• Corrective Actions

• Comments

Unit Safety Representative Safety Spot Inspections

• Findings

• Corrective Actions

• Comments

• Findings

• Corrective Actions

• Comments

• Findings

• Corrective Actions

• Comments

USR Verification of Supervisory-Level Spot Inspections

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

Safety Education

• Supervisor Safety Course

  Yes

  No

  N/A

• # Attended

• # Scheduled

• # Overdue

• Comments

• Course IV-A, Motorcycle Safety Training (Beginner's)

  Yes

  No

  N/A

• # Attended

• # Scheduled

• # Overdue

• Comments

• Course IV-B, Motorcycle Safety Training (Sport Bike)

  Yes

  No

  N/A

• # Attended

• # Scheduled

• # Overdue

• Comments

• Motorcycle Safety Training (Refresher)

  Yes

  No

  N/A

• # Attended

• # Scheduled

• # Overdue

• Comments

• Other Safety Course

  Yes

  No

  N/A

• Course Name

• # Attended

• # Scheduled

• # Overdue

• Comments

USR Verification of Supervisory-Level Safety Briefings

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

USR Verification of Job Safety Training (JSTOs, AF55, Form1)

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

• Work Center Verified

• Observations/Issues

• Comments

Miscellaneous Safety Matters (Safety program shortfalls/strengths, upcoming safety events, suggested CC emphasis areas, etc.)

• undefined

• Report Routing

• USR Signature:

  Sign

• Date

  Date

• Commanders Signature:

  Sign

• Date

  Date