(STEP 3)

1
(STEP 3) Individual Risk Assessment (Circle
appropriate numbers) SEX Female 0 Male
5 AGE ? 25 yrs 6 26-30 yrs
4 31-35 yrs 2 gt 36 yrs
1 RANK lt SPC 5 SGT, SSG
4 SFC, WO1, CW2, 2LT, 1LT 3
MSG, CW3, CPT 2 SGM, CW4, CW5, gt MAJ
1 TIME IN COUNTRY lt6 weeks
5 gt6 --lt12 weeks 3 gt3 --lt9 months
1 gt9 --lt11months
3 30 days prior to any DEROS
5 TOUR 2nd or more tour (accompanied) 0 1st
Tour or unaccompanied 1 PERSONAL LIFE
FACTORS below are just a few examples. Any
significant personal stressors present such as a
recent death in the family, alcohol/drug abuse,
financial problems, family and/or marital
problems If present
10 LOCAL ACTIVITY (Only fill out if activity
will be in local area) Buddy System No
Buddy 10 1 other Person 3 2 or more other
persons 0 Time of planned activity Night
3 Day 0 Alcohol consumption planned 7
Individual Points Total (add circled
numbers)____
(STEP 2) Safety Pledge (Initial after each
statement) (1) I will know and not enter
off-limits establishments. _____ (2) I will
utilize the buddy system to the fullest possible
extent. _____ (3) If I drink, I will drink in
moderation. _____ (4) I will act professionally
and responsibly, and I understand that no means
NO! Sexual Assaults or unwanted advances are
not and will not be tolerated_____ (5) I will get
plenty of rest before and during my travel. ____
(6) I will walk away from dangerous
and/or potentially risky situations. ____ (7) I
will take no unnecessary risk that may endanger
my life and prevent my safe return. _____ (8) As
a dedicated Soldier, I do pledge that I will be a
professional Soldier in all my activities and
return to duty safely, remembering, A Soldiers
Life Cannot Be Replaced. _____ (9) I will not
engage in any activity involving
Human Trafficking or prostitution _____ Complete
below if driving while on leave or pass (1)I
will never drink and drive nor will I
allow drinking and driving by others around me.
_____ (2) I will use a designated driver or taxi
if going out to drink. If no transportation is
available I will call my unit CQ, Staff Duty or
MP. _____ (3) I will ensure that I (and
passengers in my vehicle) always buckle up!
_____ (4) I will avoid distractions. ____ (5) I
will obey all traffic laws and maintain
safe/legal speeds and separation distances for
conditions. ____________________
____ Signature of Individual
Date ____________ ______________ Signatu
re of First Line Leader Date
(STEP 1) 4th Chemical Company Off-Duty Risk
Assessment Use this card to assess the
risks involved in your off duty activity. First,
honestly evaluate your personal risk level.
Then, analyze the details and characteristics of
your planned travel. Upon the completion of your
assessment, brief the results to your First Line
supervisor or NCO/Officer in your Chain of
Command. Individual Data Name__________________
__ __________ Unit 2nd Platoon, 4th Chemical
Company,1BSTB Dates of Activities_______________
_____ 1st Line Supervisor____________________
REASON (Circle one) LEAVE PASS
Event 1______________________________ Transport
ation method Bus/ Airline Is alcohol involved?
Yes____ No____ Battle buddy names(s)_____ _______
____ Event 2 ______________________________ Tran
sportation method Is alcohol involved? Yes____
No____ Battle buddy names(s) ___________
If you are taking CONUS leave and have a drivers
license, you must complete the online driving
assessment (ASMIS-1 Risk Assessment Tool) at
https//safety.army.mil A copy of the completion
certificate must be attached.
2
(STEP 4) Trip Risk Assessment (Completed only
if traveling outside normal commuting
area) Destination __________________________ A
ctivity/Purpose _____________ TRANSPORTATION
(to, during and from) Motorcycle
8 POV 5 Train/Bus/Plane/Taxi/Boat
0 If taking POV, driving experience
select one lt3 yrs 5
gt3 yrs 3 TRIP select one In
Country 5 To CONUS 1 To Third
Country 10 LENGTH OF TRIP select one Distance
traveling (miles) and time (days) allowed (round
trip). Example a three-day trip totaling 350
miles is 5 points. A one-day trip totaling
greater than 350 miles is 15 points.
(STEP 5) Current Risk Level (Individual plus ()
Trip) ____ (circle one)
(STEP 6) Leaders High Risk Assessment
Tool (Completed by leader) This form is designed
to assess a soldiers risk of a serious
incident (Circle appropriate numbers)
Low Moderate High Ex High
Age Under 28 Age Under 28 Age Under 28 1
Grade E-1 thru E-6, WO1, CW2, O-1, O-2, Grade E-1 thru E-6, WO1, CW2, O-1, O-2, Grade E-1 thru E-6, WO1, CW2, O-1, O-2, 1
Gender Male Gender Male Gender Male 1
Marital Status Single Marital Status Single Marital Status Single 1
Adverse administrative actions Each counseling statement / letter of reprimand (past year) Each company Grade Article 15 in past year Each Field Grade Article 15 in past year Adverse administrative actions Each counseling statement / letter of reprimand (past year) Each company Grade Article 15 in past year Each Field Grade Article 15 in past year Adverse administrative actions Each counseling statement / letter of reprimand (past year) Each company Grade Article 15 in past year Each Field Grade Article 15 in past year 1ea 2ea 3ea
Self control factors Demonstrates lack of control, mood swing, or quick temper (0 no temper noted 5 bad temper) Self control factors Demonstrates lack of control, mood swing, or quick temper (0 no temper noted 5 bad temper) Self control factors Demonstrates lack of control, mood swing, or quick temper (0 no temper noted 5 bad temper)
Major life changes in past year, i.e. arrest, serious family health problems, marriage/relationship difficulties, etc. Major life changes in past year, i.e. arrest, serious family health problems, marriage/relationship difficulties, etc. Major life changes in past year, i.e. arrest, serious family health problems, marriage/relationship difficulties, etc. 2
Moving Traffic Violations in last 3 years Inattentive driving/Failure to maintain control 10 mph over limit 15 mph over limit 20 mph over limit or reckless operation DWI/DUI Moving Traffic Violations in last 3 years Inattentive driving/Failure to maintain control 10 mph over limit 15 mph over limit 20 mph over limit or reckless operation DWI/DUI Moving Traffic Violations in last 3 years Inattentive driving/Failure to maintain control 10 mph over limit 15 mph over limit 20 mph over limit or reckless operation DWI/DUI 1 1 2 4 10
Financial irresponsibility (bad checks, unpaid credit card, letter of indebtedness, etc) Financial irresponsibility (bad checks, unpaid credit card, letter of indebtedness, etc) Financial irresponsibility (bad checks, unpaid credit card, letter of indebtedness, etc) 1
Alcohol or other drug abuse (score only one factor) Drinks 5 or more drinks at a sitting After drinking, doesnt remember what happened Was involved in an alcohol related incident/curfew violation Alcohol or other drug abuse (score only one factor) Drinks 5 or more drinks at a sitting After drinking, doesnt remember what happened Was involved in an alcohol related incident/curfew violation Alcohol or other drug abuse (score only one factor) Drinks 5 or more drinks at a sitting After drinking, doesnt remember what happened Was involved in an alcohol related incident/curfew violation 5 8 8
Compulsive Gambling (score only one factor) Loses more than planned Borrows money to gamble Talks about gambling constantly Compulsive Gambling (score only one factor) Loses more than planned Borrows money to gamble Talks about gambling constantly Compulsive Gambling (score only one factor) Loses more than planned Borrows money to gamble Talks about gambling constantly 2 4 3
Assessment of Above Risk Factors Assessment of Above Risk Factors Risk Score 0-6 Low 7-11 Medium 12-14 High 15 Extreme Risk Score 0-6 Low 7-11 Medium 12-14 High 15 Extreme
This form is designed to assess a soldiers risk of a serious incident Soldiers that score 7 should be informally counseled. Soldiers that score 12 should be referred to the 1SG and/or CDR. Soldiers that score 15 should be referred to the appropriate agency for professional assessment (ASAP, Mental Health, etc) This form is designed to assess a soldiers risk of a serious incident Soldiers that score 7 should be informally counseled. Soldiers that score 12 should be referred to the 1SG and/or CDR. Soldiers that score 15 should be referred to the appropriate agency for professional assessment (ASAP, Mental Health, etc) This form is designed to assess a soldiers risk of a serious incident Soldiers that score 7 should be informally counseled. Soldiers that score 12 should be referred to the 1SG and/or CDR. Soldiers that score 15 should be referred to the appropriate agency for professional assessment (ASAP, Mental Health, etc) This form is designed to assess a soldiers risk of a serious incident Soldiers that score 7 should be informally counseled. Soldiers that score 12 should be referred to the 1SG and/or CDR. Soldiers that score 15 should be referred to the appropriate agency for professional assessment (ASAP, Mental Health, etc)
Leaders Name Date Date Date
If the Soldier is driving review the ASMIS-1 Risk Assessment Tool printout Leaders Initials Leaders Initials Leaders Initials
0-20 21-30 31-40
41
Now take this form to your Supervisor.
Supervisor- Fill out step six, counsel, make
control decisions and implement controls with
subordinate. CONTROLS
FOR PASSES/LEAVES/HOLIDAYS 1. Out-briefed by E-7
or above -5 2. Out-briefed by E-6 or below
-3 3. Alternate transportation method (that
reduces POV use) (Bus/Plane/Train/Boat) -5 4.
Attended formal training or counseling outside of
the command that was directly related to the
stressor -6 5. Retraining on Every Drive
Counts Video -3 6. Emergency POCs at
every location traveled thru -1 7. Leave
extension policy reviewed
-1 8. Detailed schedule exists accounting for
all activities during
period
-5 9. Experience with sporting event
-1 10. Familiarity with location
being visited -2 In Korea travel
or activity 1. Korea Safety Re-brief (using
checklist) -5 CONUS Travel 1.
Emergency funds available (example AER)
-5 2. Commercial air versus Space-A Travel
-1 Other Country Travel 1. Register at
local embassy
-5 2. Emergency funds available
-2 3. G/S-2 brief tailored to
country traveling to -5 CONTROL
POINTS _____ Individual points plus () Trip
points, minus (-) Control points Residual Risk
_____ points
TIME ALLOWED (days)
gt350 350 250 lt150
M I L E S
Reason for Travel select all that
apply Emergency Leave 4 Party /
celebration 4 Personal Issue Resolution 4 Mid-tour
Leave 3 Seasonal Conditions (rain, heat, snow)
3 Non-organized Sporting Event 3 Shopping 2 Frien
d visit 2 Military Sporting Event
(participation) 1 Cultural experience 1 Family
visit 1 Other__________________________ Trip
Points Total _____
Circle Residual Risk Level (after controls)
Low Moderate High Ex High
0-20 21-30
31-40 41
LOW Soldier should be informally counseled by
Supervisor MEDIUM Soldier should be formally
counseled by Supervisor HIGH Soldier should be
formally counseled by 1SG or CDR Extremely HIGH
Soldier leave, pass or trip controls should be
modified to bring risk to an acceptable level
prior to approval.