This form requires collecting and maintaining information protected by the Privacy Act of 1974. Form will be safeguarded from unauthorized disclosure. Purpose: To assist safety professionals in making identification of individuals and to obtain required personal information to complete mishap reports. Routine Use: Used to (a) Established the severity of injury/illness and to ensure proper reporting accountability within the Samara Company; (b) Identify causes of illness/injuries so supervisors and Managers can take appropriate action to eliminate or control unsafe and unhealthy conditions; (c) Prepare statistical and historical reports; (d) Provide documentation for cumulative summation of treatment causes.