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Use to report the completion of survivability tasks. Survivability tasks include digging, revetment, camouflage, and hardening of buildings. Reference: FM 5-34, FM 5-100, and FM 5-102.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — UNIT TYPE __________________________________(Type of Unit)

LINE 4 — TASK SERIAL NUMBER________________________(Unique Task Identifying Number)

LINE 5 — OBSTACLE ZONE/BELT NUMBER _______________(Zone, Belt Letter and Number)

LINE 6 — SURVIVABILITY MISSION______________________(Type of Mission, Protective Works, Camouflage)

LINE 7 — SURVIVABILITY TASK_________________________(Task, CP, Fighting Positions)

LINE 8 — TYPE OF POSITION ___________________________(Type of Position)

LINE 9 — ECHELON____________________________________(Echelon of Unit)

LINE 10 — MAP SHEET NUMBERS _______________________(Map Sheet Numbers Relevant to Report)

LINE 11 — NAME OF NEAREST TOWN____________________(Name of Nearby Town)

LINE 12 — COMPLETION TIME__________________________(DTG When Task Was Completed)

LINE 13 — NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report

LINE 14 — AUTHENTICATION___________________________(Report Authentication)

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