CMMS Maintenance Software Resources - Maintenance-Reports-and-Records-69 Page 69

II. O&M Improvement Reporting System

is a sample of a properly completed form PO&M-171. The summary report shall be prepared and

distributed within 30 days after completion of the confidential report. It must be concise and complete to
provide for meaningful study and discussion of the Incident. One copy of the report shall be provided the
Project Operation Services, Code D-5140, Denver Office; and one copy shall be forwarded to the Chief,
Facilities Engineering Branch, Code D-5210, Denver Office.

Detailed instructions for reporting on Items, as they appear in sequence on the form, are as follows:

Sequence

Item Description

(1)

Region

Region in which the incident occurred.

(2)

Report No.

Regional report number.

(3)

Date

Date of incident.

(4)

Time

Time of incident.

(5)

Type of Report

Indicate with an "X" the type of report

(6)

Function Being

Indicate with an "X" the function being performed

Performed

at the time of the incident. This Is not necessarily
the employees job classification.

(7)

Result of Incident

Indicate with an "X" the appropriate item or items
defining the result of the Incident.

(8)

Cause of Incident

Indicate with an "X" the appropriate item or items

or condition

defining the cause of the incident or condition.

(9)

Narrative Description

A narrative summarization of the incident including:

of Incident or

(a) Events leading up to the incident, with remarks on

Condition

time available to accomplish required procedure,
stress, disturbing or distracting factors, etc.

(b) Consequences, such as injuries, damage, service
impairment, etc.

(10) Consequences

Narrative explanation of the cause(s) of the incident

(FIST 1-3 12/89)