NASA Headquarters' Directives
HQpr 8621.1 Effective Date: November 08, 2011 Expiration Date: June 08, 2019 Responsible Office: LA	Mishap Reporting, Investigating, and Recordkeeping Program and Plan

This document is uncontrolled when printed.
Check the NASA Online Directives Information System (NODIS) Library
to verify that this is the correct version before use.

Appendix K: Example of HQ Type C, Type D, and Low- Visibility Incident/Mishap Report

TO: ABC/Name

FROM: XYZ/Name

Subject: Investigation of Mishap (Title), IRIS No.

The investigation of the (Title) mishap has been completed, and the results are as follows:

Incident Description: (What happened, when it happened, who reported it, what actions were taken and the timeline).

Finding: (What the investigation revealed) Discussion:

Proximate Cause(s), Root Cause(s), and Contributing Factors:

Recommendations:

Lessons Learned (if any):

Name

MIT Chairperson's or MI's Name