ACCIDENT REPORT/SERIOUS INCIDENT REPORT [SIR]
LINE 1 — DATE AND TIME_______________________________(DTG of Report)
LINE 2 — UNIT_________________________________________(Unit Making Report)
LINE 3 — CATEGORY___________________________________(Category 1 or 2)
LINE 4 — TYPE_________________________________________(Type of Incident)
LINE 5 — TIME OF INCIDENT____________________________(DTG of Incident)
WEEK END/HOLIDAY__________________________(Indicate YES or NO and Include Holiday Name)
LINE 6 — LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator)
LINE 7 — PERSONNEL__________________________________(Personnel Involved)
a. (SUBJECT)
(1)________________________(Name, Injury, Fatality)
(2)________________________(Pay Grade)
(3)________________________(SSN)
(4)________________________(Race)
(5)________________________(Sex)
(6)________________________(Age)
(7)________________________(Position (CDR, PSG, Gunner))
(8)________________________(Security Clearance)
(9)________________________(Unit, Station, and MACOM Assigned)
(10)_______________________(Duty Status (Leave))
b. (VICTIM)
(1)________________________(Name, Injury, Fatality)
(2)________________________(Pay Grade)
(3)________________________(SSN)
(4)________________________(Race)
(5)________________________(Sex)
(6)________________________(Age)
(7)________________________(Position (CDR, PSG, Gunner))
(8)________________________(Security Clearance)
(9)________________________(Unit, Station, and MACOM Assigned)
(10)_______________________(Duty Status (Leave))
**Repeat lines 7a (1-10) through 7b (1-10) up to four times to transmit multiple data sets. Assign sequential line numbers to succeeding iterations; for example, first iteration a (1) through a (10) or b (1) through b (10); second iteration a (11) through a (20) or b (11) through b (20); third iteration a (21) through a (30) or b (21) through b (30); fourth iteration a (31) through a (40) or b (31) through b (40).
LINE 8 — SUMMARY___________________________________(Summary of Incident)
LINE 9 — PUBLICITY___________________________________(Adverse or Anticipated Publicity)
LINE 10 — COMMANDER_______________________________(Commander Reporting)
LINE 11 — POC________________________________________(Unit POC/Duty Position)
LINE 12 — DOWNGRADE_______________________________(Downgrading Instructions)
LINE 13 — NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report
LINE 14 — AUTHENTICATION___________________________(Report Authentication)
ACCIDENT SUPPLEMENT (GROUND (GRND)/AIRCRAFT (AC))
LINE 14A — POC_______________________________________(E-mail, Phone, DSN)
LINE 14B — MACOM___________________________________(TRADOC, FORSCOM, USAREUR)
LINE 14C — ACCIDENT CLASS__________________________(GRND/AC-A or B AC-C)
LINE 14D — WEATHER_________________________________(Visibility, Light Level, Precipitation, Wind)
LINE 14E — NIGHT VISION DEVICE______________________(Yes, Type, Nomenclature. For Example, NVG-AN/ PVS-5, Abrams Thermal Viewer, No)
LINE 14F — MILITARY INSTALLATION___________________(Nearest Site)
LINE 14G — EXPLOSIVE, HAZARDOUS MATERIAL_________(Involved: Yes or No, Secured: Yes or No)
LINE 14H — ACCIDENT SITE SECURED IAW AR 385-40_____(Yes or No)
LINE 14I — ACCIDENT SITE DISTURBED__________________(Yes or No)
LINE 14J — PHOTOS OF DISTURBING SCENE_____________(Yes or No)
LINE 14K — FLIGHT DATA RECORDER INSTALLED________(Yes or No)
LINE 14L — LOCAL ACCIDENT INVESTIGATION BOARD APPT_(Yes or No)
LINE 14M — NEAREST AIRFIELD_________________________(4000 Ft. Min. Runway)
LINE 14N — NEAREST COMMERCIAL AIRFIELD___________(Name, Town, State)
LINE 14O — TYPE OF EQUIPMENT_______________________(M1 Abrams, AH64,
30KW, Gen)
LINE 14P — AC SERIAL NUMBER________________________(Serial, Tail Number)
LINE 14Q — TYPE MISSION_____________________________(Training, Svc, Single Ship, Multi Ship)
LINE 14R — NAP OF THE EARTH_________________________(Yes or No)
LINE 14S — FLIGHT RULES______________________________(VFR/IFR)
