Driving Mishap Risk Indicator
Self Assessment Survey
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Instructions: Assign points for the following risk factors
as they apply.
Total points determine an individual's relative risk
level.
Directions for use of this form:
- Supervisor will discuss completed form results with
interviewee and may discuss results with the chain of command for the purpose of the
individual's welfare. A record may be made of counseling, however recommend gross
score/result or "low, medium, or high" risk levels be recorded in lieu of
answers to particular questions.
- Information or statements made to the supervisor
concerning items on this form CANNOT be used in any adverse proceeding,
administrative or criminal.
- Form is property of interviewee only and will not be
retained by command or supervisor. The interviewee may retain this completed form if
desired, however recommend this document be destroyed/shredded ASAP after counseling.
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RISK FACTOR |
POINTS |
| 1. AGE |
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25 YEARS OR YOUNGER = 1 PT |
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26 OR OLDER = 0 PTS |
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| 2. PAY GRADE |
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E-5 AND BELOW = 1 PT |
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E-6 AND ABOVE = 0 PTS |
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| 3. SEX |
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MALE = 1 PT |
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FEMALE = 0 PTS |
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| 4. MARITAL STATUS |
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SINGLE = 1 PT |
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MARRIED = 0 PTS |
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| 5. DRIVING RECORD |
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1 OR MORE MOVING VIOLATIONS LAST 12 MOS = 1
PT |
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| 6. TIME SINCE DEPLOYMENT
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DEPLOYED OVER 30 DAYS AND HOME LESS THAN 30 DAYS =
2 PTS |
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OTHERWISE= 0 PTS |
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| 7. DISTANCE TO TRAVEL |
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LESS THAN 500 MILES = 0 PTS |
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500 THRU 1000 MILES = 1 PT |
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OVER 1000 MILES = 2 PTS |
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| 8. INCIDENTS OF ALCOHOL ABUSE
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4 PTS PER INCIDENT |
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| 9. RATIO OF TRAVEL DAYS TO
TOTAL LEAVE |
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LESS THAN 1 TO 5 = 0 PTS |
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1 TO 4 = 1 PT |
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GREATER THAN 1 TO 4 = 2 PTS |
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| 10. REST PRIOR TO DEPARTURE
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LESS THAN 8 HRS = 1 PT |
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| 11. HOUR OF RETURN TO DUTY
SECTION |
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LESS THAN 12 HOURS PRIOR TO NEXT WORK
DAY = 1 PT |
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| 12. DRIVING ALONE |
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YES = 1 PT |
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| 13. PERSONAL STRESSORS |
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1 PT FOR EACH: |
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MARITAL TROUBLES |
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DEATH IN THE FAMILY |
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CAREER DECISION LOOMING |
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| 14. MOTORCYCLE TRAVEL |
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TRAVELING BY MOTORCYCLE? = 1 PT |
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| 15. TRAVELING DURING HOLIDAY
PERIODS |
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YES = 1 PT |
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TOTAL POINTS :
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Note: If the
total points exceed 10, the individual has a greater than average risk for a traffic
mishap. The supervisor/branch/division officer should work with the individual to reduce
the risk factors (allow for more travel time, take more leave, adjust the time of
departure/arrival, travel with a companion, etc.) ANALYSIS
The following areas of excessive risk were noted:
The solutions for these excessive risk factors are:
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