Form OPNAVINST 5102/10 OPNAVINST 5102/10 Safety Investigation Report Advice to Witness

SAFETY INVESTIGATION REPORT (SIR) ENCLOSURE

ADVICE TO WITNESS

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 41 4101-4118, the Government Employees Training Act of 1958; 5 U.S.C. §301, Departmental Regulations; 10 U.S.C. §5013, Secretary of the Navy; 10 U.S.C. §5041, Headquarters,
Marine Corps; E.O. 12196, Occupational Safety and Health Programs for Federal Employees; DoD Instruction 6055.07, Mishap Notification, Investigation, Reporting, and Record Keeping; OPNAVINST
5102.1D/MCO P5102.1B, Navy & Marine Corps Mishap and Safety Investigation, Reporting, and Record Keeping Manual; OPNAVINST 3750.6S, Naval Aviation Safety Management System; DoD 6025.18-R,
DoD Health Information Privacy Regulation; and E.O. 9397 (SSN), as amended, SORN NM03750-1.
PURPOSE: To capture injuries/fatalities, occupational illness required by Occupational Safety and Health Administration (OSHA) and pertinent information for property damage occurring during the
Department of the Navy operations. To ensure all DoD military and personnel received the required safety, fire, security, force protection, and emergency management training courses necessary to perform
assigned duties and comply with Federal, DoD, and Navy related regulations. To provide jump logs and/or on-duty dive and jump exposure data to individual and/or other DoD agencies.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended these records contained therein may specifically be disclosed outside the
DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD Blanket Routine Uses that appear at the beginning of the Navy's compilation of system of record notices may apply to this system.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in an inability to provide accurate information for risk assessments, safety investigations, and additional services.
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, OMB 0703-0065, is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall
be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

THIS IS PART OF A NAVY SHORE MISHAP INVESTIGATION REPORT
LIMITED DISTRIBUTION AND SPECIAL HANDLING REQUIRED BY OPNAVINST 5100.23E
THIS STATEMENT IS NOT PRIVILEGED AND MAY BE DISCLOSED
PLEASE READ THIS STATEMENT CAREFULLY
CERTIFY THAT YOU UNDERSTAND IT BY YOUR SIGNATURE AT THE BOTTOM
a.
b.
c.
d.
e.
f.

I understand that:
I have been requested to voluntarily provide information to a SIR Board conducting an investigation of a defined
Navy shore mishap.
I AM NOT being requested to provide statement under oath or affirmation.
Disclosure of personal information by me is voluntary, and that failure to provide such information will have no direct effect
on me.
The purpose of the information provided by me is to determine the cause of a mishap and/or the damage and/or injury occurring in connection with that mishap.
All information provided by me to the Mishap Board will be used ONLY for safety purposes. It is further understood, however,
that the information provided by me or contained in this report may be released in response to a Freedom of Information Act
(FOIA) or Department of Labor/OSHA request.
Although releasable, the information provided by me shall NOT be used by the Government:
(1) In any determination affecting my interests.
(2) As evidence to obtain evidence in determining misconduct or line of duty status of killed or injured personnel.
(3) As evidence to determine my responsibility or that of other personnel from the standpoint of discipline.
(4) As evidence to assert affirmative claims on behalf of the government.
(5) As evidence to determine the liability of the government for property damage caused by the mishap.
(6) As evidence before administrative bodies, such as Officer/Enlisted Separation Boards, Judge Advocate General Manual
investigations/inquiries, Naval Aviator/Naval Flight Officer Evaluation Boards (FNAEB) or Marine Corps Field Flight
Performance Boards (FFPB).
(7) In any other punitive or administrative action taken by the Department of the Navy.
(8) In any other investigation or report of the mishap about which I have been asked to provide information.

1. STATEMENT (Continue on reverse and/or attach seperate sheets(s) as necessary)

2. PRINTED NAME (First, Middle, Last)

4. DATE

5. RANK/RATE

6. ADDRESS WHERE YOU MAY BE LOCATED

OPNAV 5102/10 (Ver Jul 2019))

3. SIGNATURE

6. SERVICE

7. TELEPHONE NUMBER