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Form AC 3900-11 - Mike Monroney Aeronautical Center Non-Injury Mishap Form

Document Information

Number
AC 3900-11
Title
Mike Monroney Aeronautical Center Non-Injury Mishap Form
Prescribing Order
AC 3900.21J - Mike Monroney Aeronautical Center Occupational Safety and Health Program
Status
Active
Edition date
2023-05-04
Orientation
Portrait
Unit of issue
EA
Office of Primary Responsibility
AMP-100
Access Restriction
FAA Network Only
Description

The Aeronautical Center Non-Injury Mishap Form is required when an employee has a Motor Vehicle (Non-Injury), Near Miss, or Property Damage Mishap. The definitions for these items are below. If your mishap involves an injury, please complete an OSHA Form 301 in the ECOMP system: https://www.ecomp.dol.gov/#/

  • Motor Vehicle (Non-Injury): An incident where a motor vehicle collides with another object. This includes other vehicles, structures, buildings, people or animals.
  • Near Miss: An unplanned event that did not result in injury, illness, or property damage, but had the potential to do so.
  • Property Damage: An incident that results in physical damage or destruction of real property, government property, or personnel property.

Form 3900-1 must be submitted to 9-AMC-AMP-100A@faa.gov and Jason.e.Palmeter@faa.gov within five working days of the Mishap.

Contact information
Jason Palmeter
jason.e.palmeter@faa.gov
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