DA Form 7851 "Fitness Facility Risk Assessment Worksheet"

What Is DA Form 7851?

This is a military form that was released by the U.S. Department of the Army (DA) on May 1, 2019. The form, often mistakenly referred to as the DD Form 7851, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 3-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Additional instructions and information can be found on page 3 of the document;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 7851 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 7851 "Fitness Facility Risk Assessment Worksheet"

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1. DATE (YYYYMMDD):
FITNESS FACILITY RISK ASSESSMENT WORKSHEET
For use of this form, see TB MED 531; the proponent agency is OTSG.
2. FACILITY NAME
FACILITY LOCATION
3. PERIOD ASSESSED (Report Date - YYYYMMDD)
4. COMPLETETD BY:
1st Report:
Last Report:
5. FACILITY CHARACTERIZATION (Types of services offered within the operation. Check all that apply.)
A
Gymnasium or fitness room – (weight room, cardio room, athletic courts)
Extremely High (Monthly)
A
Bulk equipment management - (storage and issue of sports gear and fitness accessories)
High (Quarterly)
B
Shower or locker rooms
Moderate (Semi-annual)
C
Personal item issue - (towels, athletic clothing, protective eyewear)
Low (Annual)*
C
On-site laundry
D
Sauna or steam room
E
Indoor pool, spa/hot tub, or whirlpool (therapy pool)
F
Food concession – (includes juice/smoothie bar)
G
Massage (whole body) – Conduct a separate assessment (using this form) for independent concessions not operated within a fitness center.
6. OPERATION TYPE (Mark an “X” next to the Operation Type that best summarizes the Facility Characterization codes marked at item 5, above. Complexity of the facility increases from Type I to Type VI, with
Type VI being the most complex. Underlined values reflect the operational component within the group that increases the risk potential.)
Type II – A C or G only
Type III – A B or A B C or B C G
Type IV – A B D or A B C D
Type I – A only
Type V – A B C D E or A B C D E F
Type VI – A B C D G or A B C D E F G
OTHER – Specify:
7. PRIMARY POPULATION SERVED (Mark an “X” next to the item description that best characterizes
the primary customer base using this facility.)
High readiness TO&E
150 or less customers (0 points)
151 – 300 customers (1 points)
TO&E units
General population
Deployment
IET/AIT; Mobilization
Hospital; Contingency Camp
301 – 500 customers (2 points)
9. INSPECTION HISTORY (List each inspection document in the Inspection Report Review Log and refer to the instruction page to complete this section.)
a. Inspection Reports (Enter the form number or survey report in the Inspection Report Review Log on page 2.
b. Calculations
AWARDED POINTS
Non-conformance
BT
RF
CF
BV
R
TV
CV
BV x NCV
Base Total
Risk Factor
Critical Factor
Baseline Value
# of Reports
Total # of Violations
# of Critical Violations
BV x R
TV ÷ BT
CV ÷ TV
BV = 20
R = _______
BT = _______
TV = _______
CV = _______
RF = _______
CF = _______
NCV = _______
10. TREND – Non-compliance weighted average during
g
%
11. NUMBER OF UNSATISFACTORY INSPECTIONS (Includes Follow-up inspections.)
the assessment period (NCV x 100 = %)
0 (0 points)
1 (2 points)
Note: Trends > 20% are indicative of poor active managerial controls within the operation.
2 (7 points)
Add the Awarded Points from items 8, 9, and 11 to get the Total Points.
TOTAL POINTS
12. FACILITY SCORE (The Facility Score is represented by the Total Points. Use the
Facility Score to determine the facility risk rating.)
DA FORM 7851, MAY 2019
APD AEM v1.00
1. DATE (YYYYMMDD):
FITNESS FACILITY RISK ASSESSMENT WORKSHEET
For use of this form, see TB MED 531; the proponent agency is OTSG.
2. FACILITY NAME
FACILITY LOCATION
3. PERIOD ASSESSED (Report Date - YYYYMMDD)
4. COMPLETETD BY:
1st Report:
Last Report:
5. FACILITY CHARACTERIZATION (Types of services offered within the operation. Check all that apply.)
A
Gymnasium or fitness room – (weight room, cardio room, athletic courts)
Extremely High (Monthly)
A
Bulk equipment management - (storage and issue of sports gear and fitness accessories)
High (Quarterly)
B
Shower or locker rooms
Moderate (Semi-annual)
C
Personal item issue - (towels, athletic clothing, protective eyewear)
Low (Annual)*
C
On-site laundry
D
Sauna or steam room
E
Indoor pool, spa/hot tub, or whirlpool (therapy pool)
F
Food concession – (includes juice/smoothie bar)
G
Massage (whole body) – Conduct a separate assessment (using this form) for independent concessions not operated within a fitness center.
6. OPERATION TYPE (Mark an “X” next to the Operation Type that best summarizes the Facility Characterization codes marked at item 5, above. Complexity of the facility increases from Type I to Type VI, with
Type VI being the most complex. Underlined values reflect the operational component within the group that increases the risk potential.)
Type II – A C or G only
Type III – A B or A B C or B C G
Type IV – A B D or A B C D
Type I – A only
Type V – A B C D E or A B C D E F
Type VI – A B C D G or A B C D E F G
OTHER – Specify:
7. PRIMARY POPULATION SERVED (Mark an “X” next to the item description that best characterizes
the primary customer base using this facility.)
High readiness TO&E
150 or less customers (0 points)
151 – 300 customers (1 points)
TO&E units
General population
Deployment
IET/AIT; Mobilization
Hospital; Contingency Camp
301 – 500 customers (2 points)
9. INSPECTION HISTORY (List each inspection document in the Inspection Report Review Log and refer to the instruction page to complete this section.)
a. Inspection Reports (Enter the form number or survey report in the Inspection Report Review Log on page 2.
b. Calculations
AWARDED POINTS
Non-conformance
BT
RF
CF
BV
R
TV
CV
BV x NCV
Base Total
Risk Factor
Critical Factor
Baseline Value
# of Reports
Total # of Violations
# of Critical Violations
BV x R
TV ÷ BT
CV ÷ TV
BV = 20
R = _______
BT = _______
TV = _______
CV = _______
RF = _______
CF = _______
NCV = _______
10. TREND – Non-compliance weighted average during
g
%
11. NUMBER OF UNSATISFACTORY INSPECTIONS (Includes Follow-up inspections.)
the assessment period (NCV x 100 = %)
0 (0 points)
1 (2 points)
Note: Trends > 20% are indicative of poor active managerial controls within the operation.
2 (7 points)
Add the Awarded Points from items 8, 9, and 11 to get the Total Points.
TOTAL POINTS
12. FACILITY SCORE (The Facility Score is represented by the Total Points. Use the
Facility Score to determine the facility risk rating.)
DA FORM 7851, MAY 2019
APD AEM v1.00
INSPECTION REPORT REVIEW LOG
(List the reports reviewed for this assessment period. Use to complete worksheet items 3 and 9 on page 1)
Number of
Report Type
Number of Critical
Report Date
Violations
(form number/version)
Violations
(Critical + Non - critical)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Totals:
(R)
(AV)
(C)
Example:
DOEHRS
14 Oct 2017
6
3
DA Form XXXX
10 Apr 2018
3
0
DOEHRS
23 Sep 2018
5
2
Totals:
(R)
3
(AV)
14
(C)
5
DA FORM 7851, MAY 2019
APD AEM v1.00ES
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INSTRUCTIONS FOR COMPLETING THE FITNESS FACILITY RISK ASSESSMENT WORKSHEET
1. DATE. Date risk assessment was completed.
2. FACILITY NAME. Name of the establishment must be distinguishable from other similar facilities. Include the building number with the facility name (e.g., B14443 Field House; 516 Sparks
Fitness Center; 2004 B Company Barracks). Provide the name of the military installation where the operation is located.
3. PERIOD ASSESSED. Dates of the first and last inspection report reviewed for the current risk assessment period. Include all Routine and associated Follow-up inspections.
4. COMPLETED BY. Rank and first and last name of the person completing the risk assessment. The assessment should be conducted or reviewed for accuracy by a senior individual
(Supervisor, Department Chief).
5. FACILITY CHARACTERIZATION. Mark each item that describes the types of activities and services associated with the operation.
6. OPERATION TYPE. The Operation Type represents the combined services/activities that are available at the facility. Operational hazards and/or the complexity of the services offered increase
as the Operation Type increases from Type I to Type VI. Additional guidance --
- Type II (G only) and Type III (BCG) --These Operation Types represent massage facilities that are operated independent from a fitness center.
- Type VI is selected when massage services are integrated with the fitness center.
- OTHER --Select when a specialty service is provided, but not listed in block 5. List all applicable Activity Codes from block 5 and then identify the Operation Type that closely matches the
overall facility characteristics. Note: Physical therapy facilities operated through the medical treatment facility do not require a risk assessment, but may be evaluated using this worksheet.
7. PRIMARY POPULATION SERVED. The customer base primarily serviced by the facility due to proximity.
- General Population: Mixed customer base that does not distinguish a unique population; local community.
- TO&E Units: Facility is located [CONUS or OCONUS] at home station and is situated in close proximity to support TO&E units.
- High Readiness TO&E Unit: Facility is located [CONUS or OCONUS] at home station and in close proximity to Special Operations, Division Readiness Brigade, or other specialty unit with
short notice deployment designation.
- Deployment Setting: Facility is located at a forward operating base, camp, or similar combat or contingency operation site. Note: This category does not include detainee/prisoner sites [see
“Hospital; Contingency Camp”].
- IET/AIT; Mobilization; Readiness Training Site: Facility is located in the battalion area of a basic training or advanced initial training school; or facility primarily supports an active/reserve
component mobilization site; or facility is located near a training site where exercises last more than 2 weeks or are utilized for deployment readiness validation (e.g., NTC, JRTC).
- Hospital; Contingency Camp: Operation directly supports a medical facility, a displaced persons camp, or detainee camp.
8. AVERAGE DAILY FACILITY PATRONAGE. Average number of customers served each day. If averages vary by weekday, weekend or season, calculate the average daily rate for the year or
use the highest of the average values provided. Indicate the Awarded Points that correspond to the average facility patronage value.
9. INSPECTION HISTORY. The risk assessment consolidates an operation's performance data from all of the inspections conducted at the facility during the assessment period. For initial
assessment, review all routine and follow-up inspections conducted within the previous 24 months or the last 12 inspections, whichever method yields the greatest number of reports. For
periodic updates, only review inspection reports for the current assessment period. Update assessments annually for facilities rated Extremely High or High risk; update every 2 years for
Moderate or Low risk operations. Note: Use the Inspection Report Review Log (page 2 of the worksheet) to track the documents reviewed.
9a. Enter the reviewed inspection documents in the Inspection Report Review Log and complete the requested information.
- Baseline Value [BV]. Predetermined value represents the core sanitation and hygiene requirements (inspection criteria) that apply to all gym/fitness/massage operations.
- # of Reports [R]. The total number of documents that were reviewed for the current risk assessment period.
- Base Total [BT]. The minimum number of possible violations from the fitness operation inspection reports that were reviewed. Calculate by multiplying the Baseline Value by the total # of
Reports: BV x R = BT
- Total # of Violations [TV]. Count the number of critical and non-critical items that were marked non-compliant for each inspection conducted during the risk assessment period; record the
numbers for each report on the Report Review Log (page 2 of the worksheet). Sum the column and mark the total in the space provided for TV in the worksheet.
- # of Critical Violations [CV]. Count the number of CRITICAL items that were marked non-compliant on each inspection report and enter the number for each report on the Report Review
Log. Sum the column and mark the total in the space provided for CV in the worksheet.
Note: Critical inspection items are indicated by an asterisk (*) next to the item number on the DA inspection form and are identified with the corresponding provision in TB MED 531. Critical
items are not distinguished on the DOEHRS Survey Report and must be identified using TB MED 531.
9b. Calculations. Round all values to 3 decimal places (e.g., 0.1357 rounds up to 0.136; 0.2643 rounds down to 0.264)
- RF - The Risk Factor is a decimal representation of the average rate of non-compliance during the current assessment period. Calculate by dividing the Total # of Violations by the Base
Total: TV ÷ BT = RF
- CF - The Critical Factor is a decimal representation of the percent of violations attributed to critical items. Calculate by dividing the # of Critical Violations by the Total # of Violations: CV ÷
TV = CF [Note: When there are no critical violations, the CF value is zero and NCV does not need to be calculated.]
- NCV - The Non-Compliance Value reflects the degree of non-conformance occurring within an operation. The weighted value accounts for the increased health risk attributed to critical
violations. Calculate by multiplying Risk Factor by Critical Factor and then adding the value to the Risk Factor: (RF x CF) + RF = NCV
[Note: When the CF value is zero, the NCV value is equal to the RF value.]
- Awarded Points for Non-conformance. Multiply the Baseline Value by the Non-Compliance Value: BV x NCV
Example: When BV=20, R=3, BT=60, TV=14, and CV=5, then RF= TV ÷ BT = 14 ÷ 60 = 0.233; CF= CV ÷ TV = 5 ÷ 14 = 0.357;
NCV= (RF x CF) + RF = (0.233 x 0.357) + 0.233 = 0.316; and Awarded Points= BV x NCV = 20 x 0.316 = 6.32
10. TREND. The “trend” reflects the operation's pattern of non-conformance to prescribed sanitation and hygiene standards. An intervention strategy should be applied by public health regulators
to help improve active managerial controls when the trend value is greater than 20%.
11. NUMBER OF UNSATISFACTORY INSPECTIONS. From the assessed reports, to include Follow-up inspections, count the total number of reports that were rated “unsatisfactory” or “non-
compliant”. Enter the corresponding points in the adjacent space for Awarded Points. The pre-assigned values may not be increased or decreased.
12. FACILITY SCORE. Add up the Points from items 8, 9b and 11. Round all decimal values up to nearest whole number. Using the Probability table, find the point of intersect where Facility
Score and Operation Type meet. Find the point of intersect in the Severity table where Primary Population Served and Operation Type meet. Find the point of intersect in the Risk Rating
table where the Severity and Probability values meet.
13. RISK RATING AND INSPECTION FREQUENCY. Mark the appropriate risk rating box located at the top of the worksheet. The number of inspections planned for the upcoming year should
correspond to the operation's Risk Rating.
DA FORM 7851, MAY 2019
APD AEM v1.00ES
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