Fillable OVERSEAS MOTOR VEHICLE MISHAP REPORT Form DS-1664

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OVERSEAS MOTOR VEHICLE MISHAP REPORT Form DS-1664

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The OVERSEAS MOTOR VEHICLE MISHAP REPORT Form DS-1664 form is 4 pages long and contains:

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  • 88 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

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U.S. Department of State
OVERSEAS MOTOR VEHICLE MISHAP REPORT
DS-1664
06-2017
Instructions Page
PRIVACY ACT STATEMENT
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-1664, Overseas Motor Vehicle Mishap Report (15 FAM 963) is required whenever a motor vehicle mishap occurs that results in personal injury
(excluding a minor/first aid injury),or vehicle or property damage is excess of $1,000.
PURPOSE: The principle purpose of the Overseas Motor Vehicle Mishap Report is to inform the safety and health official of fatalities, serious injuries or property damage associated with official vehicle operations. 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.
ROUTINES 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 focus training/assistance efforts on the information contained therein. Sufficient detail is also required to adequately evaluate events
to prevent recurrence.
NOTE: The following categories of mishaps must be reported within 12 hours as per 15 FAM:
* 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;
* Injuries or occupational illnesses, (with lost workdays), involving three or more employees;
* Any environmental contamination.
If a motor vehicle mishap results in injury or death to any employee, including tenant agency employees, family member, contractor, or local national, a DS-1663,
Report of Mishap, is also required for each individual injured or killed in the mishap. A DS-1663 is not required for minor/first aid injuries. Submit the DS-1663
concurrently with the Motor Vehicle Mishap Report.
Mishap Information Blocks:
Agency/Organization - Driver's agency/organization for reporting damaged property
Last Medical Screening - If the driver's only medical screening exam was at the time of hiring, please enter the date hired for the "Last Medical Screening" field.
Last Safe Driver Training - If the official vehicle driver has not attended a SHEM or Post safe driver training session, enter "None" under the "Last Safe Driver
Training" field. Do not include DS-related training in this field.
Last Operator Evaluation - Enter the date of the most recent operator evaluation.
Estimated Vehicle Speed (KPH) - At the time of impact.
Same Day - Identify whether the driver's shift started on the same date as the mishap occurred.
Was this Collision Preventable? - Determine if the official vehicle driver did everything reasonably possible to prevent the collision. Follow the National Safety
Council's Guide to Determine Motor Vehicle Collision Preventability.
Official Vehicle Driver Information Blocks:
Official Vehicle Data Blocks:
"Other" vehicle includes rental vehicles, taxis, or any other non-government-owned vehicle used in the conduct of official government business.
Submit completed DS-1664 (and DS-1663, if applicable) to the Post Occupational Safety and Health Officer (POSHO).
**Be sure to retain an original copy for your files. **
Police Report - If received, please include a copy.
Post - Provide post name for overseas mishaps.
Mishap Date - Provide all dates in mm-dd-yyyy format.
Mishap Time - Provide all times in hh:mm. Check a.m. or p.m.
Reporting Instructions:
Post
Last Safe Driver Training Orientation/Evaluation Drive?
Shift Start Time
Driver Name
II. OFFICIAL VEHICLE DRIVER INFORMATION
(Last, First, MI.)
(hh:mm)
Gender
Male
Agency/Organization
HR Category:
FS GS FSN EFM PSC CON
Other
Same Day
Estimated Vehicle Speed
(KPH)
Age or Date Of Birth
(mm-dd-yyyy)
TDY
(mm-dd-yyyy)
Years Employed or Date Hired
(mm-dd-yyyy)
Job Title
Female
a.m. p.m.
NoYes
Last Medical Screening (mm-dd-yyyy)
Injured
Mishap Time
U.S. Department of State
OVERSEAS MOTOR VEHICLE MISHAP REPORT
If additional government drivers are involved in this motor vehicle mishap, complete a Motor Vehicle Mishap Report form for each driver. Complete a DS-1663,
"Report of Mishap" for each person injured or killed in the mishap. Check if you are submitting DS-1663.
I. MISHAP INFORMATION
(hh:mm)
DS-1664
06-2017
Page 1 of 3
III. OFFICIAL VEHICLE DATA
Year of Vehicle Manufacturer Model Ownership:
OtherGOV
Description of Vehicle Damage
Armor:
Vehicle License Number
Type of Vehicle:
Sedan
Estimated Repair Cost
Lvl C
None
SUV Truck
Bus
Sports
Compact
Motorcycle
Other
POV
Lvl D
Police Report on file? Yes
No
Weather
Clear Fog Rain Sand
Snow
Road Condition
Visibility
Day
Night Twilight
Dry
Wet
Ice Snow Sand Unpaved Road
Location Type
Intersection Urban
Rural
Highway
Lot/Yard
Specific Location
Seatbelts Worn?
Driver
Passenger(s)
Yes
No
Yes
No N/A
Mishap Date
(mm-dd-yyyy)
Reported On (SHEM Use Only)
a.m. p.m.
Narrative Description of Mishap (Provide information on vehicle speeds, posted speed limits, traffic controls, and driver actions.)
Was this collision preventable?
Yes No
Artificial Lt
Yes No
DS-1664
Page 2 of 3
IV. OTHER DRIVERS AND VEHICLE INFORMATION
Vehicle -1 Driver's Name
Tag or ID Number
Type of Vehicle
Sedan SUV Truck Bus Sports Compact Motorcycle
Description of Damage
Vehicle - 2 Driver's Name Owner's Address
Tag or ID Number Year of Vehicle
Type of Vehicle
Sedan SUV Truck Bus Sports Compact Motorcycle
Description of Damage
Vehicle - 3 Driver's Name Owner's Address
Tag or ID Number Year of Vehicle
Type of Vehicle
Sedan SUV Truck Bus Sports Compact Motorcycle
V. WITNESSES
Description of Damage
Other
Owner's Address
Year of Vehicle
Other
Other
Phone Number
Manufacturer/Model
Estimated Repair Cost
Phone Number
Manufacturer/Model
Estimated Repair Cost
Phone Number
Manufacturer/Model
Estimated Repair Cost
Witness - 3
Witness - 2
Witness - 1
Address
Address
Address
Telephone Number
Telephone Number
Telephone Number
Supervisor's Name
POSHO's Name
Corrective Action(s) Taken.
Address
POSHO's Signature and DateSupervisor's Signature and Date
DS-1664 Page 3 of 3
IX. SUPERVISOR/POSHO INFORMATION
(mm-dd-yyyy) (mm-dd-yyyy)
VI. MISHAP DIAGRAM
Indicate on this diagram how the mishap occurred
(Describe recommended actions that will prevent recurrence of a similar mishap in the future, whether or when these actions
have been implemented.)
VIII. CORRECTIVE ACTIONS
Use this outline to sketch the scene. Write in
street or highway names or numbers.
a. Number the government vehicle(s) as G1, G2,
etc. and other vehicle(s) as O1, O2, etc. E.g.
G1
,O1 , O2
b. Use solid line to show vehicle path before the
mishap:
Use a broken line to show path after the
mishap:
c. Show any pedestrian(s) by O
d. Show any railroad by
-- -- -- -- -- -- -- --
e. Place a bold arrow in the diagram to indicate
>
NORTH
X
X
X X
X
Name of Owner
Description of Property, Damage and Estimated Repair/Replacement Cost
Telephone Number
(Enter GO for Government Property)
VII. OTHER PROPERTY DAMAGE (NON-VEHICULAR)
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OVERSEAS MOTOR VEHICLE MISHAP REPORT Form DS-1664

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Completed 13 May 2019

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