AF Form 978 "Supervisor's Mishap Report"

What Is AF Form 978?

AF Form 978, Supervisor's Mishap Report is a document necessary to assist safety professionals in making identification of individuals and to obtain required personal information to complete mishap reports.

The latest version of the form was released by the Air Force (AF) in April 2014 with all previous editions obsolete. An AF Form 978 fillable version is available for download below or can be found through the Air Force e-Publishing website.

Additional information and filing guidelines can be found in AFI 91-204, Safety Investigation, and Hazard Reporting. These instructions provide guidance that is common for investigating and reporting of all United States Air Force safety events. It applies to commanders, managers, supervisors, and safety staffs at all levels, persons who investigate and report Air Force events, and persons who handle such reports. The instructions also inform about the control and use of privileged safety reports.

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AF Form 978 Instructions

The mishaps are classified by the total direct mishap cost and severity of injury/occupational illness and include:

  • Unplanned occurrence, or series of occurrences, that result in damage to the DoD (Department of Defense) property;
  • Occupational illness of the personnel;
  • Injury to on/off duty military personnel;
  • Injury to on-duty civilian personnel;
  • Damage to the public or private property;
  • Injury or illness, caused by the DoD activities.

This form is used to establish the severity of injury/illness and to ensure proper reporting accountability within the Department of the Air Force, to identify causes of illness/injuries, so supervisors and functional managers can take appropriate action to eliminate or control unsafe and unhealthy conditions, to prepare statistical and historical reports as required by the Department of Defense, and to provide documentation for cumulative summation of treatment causes.

The Supervisor's Mishap Report needs to be completed for any injury minor to serious whether they occurred on or off duty. The document is then filed with the safety office. The form is used to document a ground mishap to the Unit Commander and Wing Safety. The installation Ground Safety Manager will review the form to determine reportability and ensure appropriate documentation. The form will be completed by the supervisor of the injured personnel and returned to the appropriate safety office within five workdays following the mishap or notification of the mishap.

The AF Form 978 presents detailed factual and analytical information about mishaps. The mishap data information includes: full name, grade/rank, age, sex, unit/office symbol, job title, duty phone, date of mishap, time of mishap, mishap occurred, duty status, days scheduled to work, work shift hours, hours on duty prior to mishap, weather conditions, light conditions, number of days since last deployment, number of days deployed in the last 365 days, location of mishap site, description of mishap, witnesses and their names, disposition of individual, type of injury/, body part(s) injured, tox testing, and treatment.

The "Property Damage" Section includes the property description, vehicle description, type/date of training, property and vehicle damage description, cost of repair and materials cost, seatbelt used, speeding, alcohol involved.

The "Supervisor, Unit Safety Representative, Commander, and Safety Office Review and Signature" Section includes these officials' names, their grades/ranks, duty phone numbers, and signatures.

Safety office fills in the following boxes: reportable - check yes or no box, the AF Safety Automated System number, mishap class, date mishap reported to safety, non-reportability reference, and the signature.

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Download AF Form 978 "Supervisor's Mishap Report"

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SUPERVISOR'S MISHAP REPORT
Privacy Act: This form requires collecting and maintaining
Authority: Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07 and AFI 91-204.
Purpose: To assist safety professionals in making
information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure.
Routine Use: Used to (a) Establish the severity of injury/illness
identification of individuals and to obtain required personal information to complete mishap reports.
and to ensure proper reporting accountability within the Department of the Air Force; (b) Identify causes of illness/injuries so supervisors and functional managers
can take appropriate action to eliminate or control unsafe and unhealthy conditions; (c) Prepare statistical and historical reports as required by Executive Order 12196
and Department of Defense; (d) Provide documentation for cumulative summation of treatment causes.
requested information may delay appropriate corrective action to ensure personal safety and reporting mishap to AFSEC.
MISHAP DATA INFORMATION
2. GRADE/RANK
3. AGE
4. SEX
1. NAME (Last, First, Middle Initial)
5. UNIT/OFFICE SYMBOL
6. DAFSC/OCC SERIES
7. JOB TITLE
8. DUTY PHONE
10. TIME OF MISHAP
11. MISHAP OCCURRED
12. ON/OFF DUTY
13. DUTY STATUS
9. DATE OF MISHAP
(24hr Format)
14. DAYS SCHEDULED TO WORK (check all that apply)
16. HOURS ON DUTY PRIOR TO MISHAP
15. WORK SHIFT HOURS (24hr Format)
to
SUN
MON
FRI
TUES
WED
THURS
SAT
17. WEATHER CONDITIONS
18. LIGHT CONDITIONS
19. # DAYS SINCE LAST DEPLOYMENT/TDY
20. # DAYS DEPLOYED/TDY IN LAST 365 DAYS
21. LOCATION OF MISHAP SITE (bldg. #, room, street name, intersection, parking lot, home, work, etc.)
22. DESCRIPTION OF MISHAP (who, what, when, where, and why; indicate the cause (s); if more space is needed use separate sheet (s) of paper)
24. WITNESS NAME(S)
23. WITNESSES
25. DISPOSITION OF INDIVIDUAL (check all that apply to include the number of days)
26. TYPE OF INJURY/INJURIES (i.e., bruise, fracture, cut, sprain, etc.)
No Medical Treatment needed or sought
Returned to restricted duty
number of days
Admitted to Hospital
number of days
Treated and released back to regular duty hours
Placed on quarters
number of days
27. BODY PART(S) INJURED (i.e., lower back, head, right knee, etc.)
Place on con leave for
number of days
First/Self aid only
Comments
AF FORM 978 20140409
The information herein is For Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. The unauthorized disclosure or
misuse of this personal information may result in criminal and/or civil penalties.
SUPERVISOR'S MISHAP REPORT
Privacy Act: This form requires collecting and maintaining
Authority: Executive Order 12196, 29 CFR 1960, 10 USC 8013, DoDI 6055.07 and AFI 91-204.
Purpose: To assist safety professionals in making
information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure.
Routine Use: Used to (a) Establish the severity of injury/illness
identification of individuals and to obtain required personal information to complete mishap reports.
and to ensure proper reporting accountability within the Department of the Air Force; (b) Identify causes of illness/injuries so supervisors and functional managers
can take appropriate action to eliminate or control unsafe and unhealthy conditions; (c) Prepare statistical and historical reports as required by Executive Order 12196
and Department of Defense; (d) Provide documentation for cumulative summation of treatment causes.
requested information may delay appropriate corrective action to ensure personal safety and reporting mishap to AFSEC.
MISHAP DATA INFORMATION
2. GRADE/RANK
3. AGE
4. SEX
1. NAME (Last, First, Middle Initial)
5. UNIT/OFFICE SYMBOL
6. DAFSC/OCC SERIES
7. JOB TITLE
8. DUTY PHONE
10. TIME OF MISHAP
11. MISHAP OCCURRED
12. ON/OFF DUTY
13. DUTY STATUS
9. DATE OF MISHAP
(24hr Format)
14. DAYS SCHEDULED TO WORK (check all that apply)
16. HOURS ON DUTY PRIOR TO MISHAP
15. WORK SHIFT HOURS (24hr Format)
to
SUN
MON
FRI
TUES
WED
THURS
SAT
17. WEATHER CONDITIONS
18. LIGHT CONDITIONS
19. # DAYS SINCE LAST DEPLOYMENT/TDY
20. # DAYS DEPLOYED/TDY IN LAST 365 DAYS
21. LOCATION OF MISHAP SITE (bldg. #, room, street name, intersection, parking lot, home, work, etc.)
22. DESCRIPTION OF MISHAP (who, what, when, where, and why; indicate the cause (s); if more space is needed use separate sheet (s) of paper)
24. WITNESS NAME(S)
23. WITNESSES
25. DISPOSITION OF INDIVIDUAL (check all that apply to include the number of days)
26. TYPE OF INJURY/INJURIES (i.e., bruise, fracture, cut, sprain, etc.)
No Medical Treatment needed or sought
Returned to restricted duty
number of days
Admitted to Hospital
number of days
Treated and released back to regular duty hours
Placed on quarters
number of days
27. BODY PART(S) INJURED (i.e., lower back, head, right knee, etc.)
Place on con leave for
number of days
First/Self aid only
Comments
AF FORM 978 20140409
The information herein is For Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. The unauthorized disclosure or
misuse of this personal information may result in criminal and/or civil penalties.
28. TOX TESTING
29. TREATMENT (also, indicate whether medications were prescribed)
PROPERTY DAMAGE
30. PROPERTY DESCRIPTION (includes serial #/part number)
31. VEHICLE DESCRIPTION
YEAR
MAKE
MODEL
REGISTRATION #
32. SPECIFICATIONS
33. SELECT TYPE/DATE OF TRAINING
34. PROPERTY & VEHICLE DAMAGE DESCRIPTION
36. SEATBELT USED
37. PPE USED
38. SPEEDING
39. ALCOHOL INVOLVED
40. ENTERED IN MUSTT
41. MAJCOM unique items
SUPERVISOR, UNIT SAFETY REPRESENTATIVE, COMMANDER AND SAFETY OFFICE REVIEW AND SIGNATURE
SUPERVISOR'S NAME, GRADE/RANK
DUTY PHONE
SIGNATURE
Click to sign
UNIT SAFETY REPRESENTATIVE'S NAME, GRADE/RANK
SIGNATURE
DUTY PHONE
Click to sign
COMMANDER'S NAME, GRADE/RANK
DUTY PHONE
SIGNATURE
Click to sign
COMMENTS
FOR SAFETY OFFICE USE ONLY
DATE MISHAP REPORTED TO SAFETY
REPORTABLE
AFSAS-NUMBER
MISHAP CLASS
NON-REPORTABILITY REFERENCE
SIGNATURE
Click to sign
AF FORM 978 20140409
The information here in is For Official Use Only (FOUO) which must be protected under the Privacy Act of 1974, as amended. The unauthorized disclosure or
misuse of this personal information may result in criminal and/or civil penalties.
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