(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 > 36 yrs +1 RANK:< SPC +5SGT, SSG +4 SFC, WO1, CW2, 2LT, 1LT +3 MSG, CW3, CPT +2 SGM, CW4, CW5, > MAJ +1 TIME IN COUNTRY:<6 weeks +5>6 --<12 weeks +3>3 --<9 months +1>9 --<11months +330 days prior to any DEROS +5TOUR2nd or more tour (accompanied) +01st Tour or unaccompanied +1PERSONAL 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 +101 other Person +32 or more other persons +0Time of planned activity:Night +3Day +0Alcohol 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-limitsestablishments. _____(2) I will utilize the buddy system to the fullestpossible extent. _____(3) If I drink, I will drink in moderation. _____(4) I will act professionally and responsibly, and Iunderstand that “no” means “NO!” Sexual Assaultsor unwanted advances are not and will not betolerated_____(5) I will get plenty of rest before and during mytravel. ____ (6) I will ‘walk away’ from dangerous and/orpotentially risky situations. ____(7) I will take no unnecessary risk that mayendanger my life and prevent my safe return. _____(8) As a dedicated Soldier, I do pledge that I will bea professional Soldier in all my activities and returnto duty safely, remembering, “A Soldiers’ LifeCannot Be Replaced.” _____(9) I will not engage in any activity involving HumanTrafficking or prostitution _____

Complete below if driving while on leave or pass

(1)I will never drink and drive nor will I allowdrinking and driving by others around me. _____(2) I will use a designated driver or taxi if going outto drink. If no transportation is available I will callmy unit CQ, Staff Duty or MP. _____ (3) I will ensure that I (and passengers in myvehicle) always buckle up! _____(4) I will avoid distractions. ____ (5) I will obey all traffic laws and maintain safe/legalspeeds and separation distances for conditions.

____________________ ____

Signature of Individual Date

____________ ______________

Signature of First Line Leader Date

If you are taking CONUS leave and have a driver’s 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.

(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______________________________Transportation method Bus/ AirlineIs alcohol involved? Yes____ No____Battle buddy names(s)_____ ___________

Event #2 ______________________________Transportation method Is alcohol involved? Yes____ No____Battle buddy names(s) ___________

(STEP 4)Trip Risk Assessment

(Completed only if traveling outside normal commuting area)

Destination: __________________________Activity/Purpose: _____________TRANSPORTATION: (to, during and from) Motorcycle +8POV +5Train/Bus/Plane/Taxi/Boat +0 If taking POV, driving experience: select one <3 yrs +5 >3 yrs +3TRIP: select oneIn Country 5To CONUS 1To Third Country 10LENGTH OF TRIP: select oneDistance 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.

8

2

5

1

13

10

6

2

15

12

7

2

3

2

1

1

>350

350

250

<150

TIME ALLOWED (days)

MILES

Reason for Travel: select all that applyEmergency Leave 4Party / celebration 4Personal Issue Resolution 4Mid-tour Leave 3Seasonal Conditions (rain, heat, snow) 3Non-organized Sporting Event 3Shopping 2Friend visit 2Military Sporting Event (participation) 1Cultural experience 1Family visit 1Other: __________________________Trip Points Total: _____

LOW: Soldier should be informally counseled by SupervisorMEDIUM: Soldier should be formally counseled by SupervisorHIGH: Soldier should be formally counseled by 1SG or CDRExtremely HIGH: Soldier leave, pass or trip controls should be modified to bring risk to an acceptable level prior to approval.

(STEP 5)Current Risk Level (Individual plus (+) Trip): ____

(circle one)

Low Moderate High Ex High

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/HOLIDAYS1. Out-briefed by E-7 or above: -5 2. Out-briefed by E-6 or below: -33. Alternate transportation method (that reduces POV use) (Bus/Plane/Train/Boat) -54. Attended formal training or counseling outside of the command that was directly related to the stressor: -65. Retraining on “Every Drive Counts” Video -36. Emergency POC’s at every location traveled thru -17. Leave extension policy reviewed -18. Detailed schedule exists accounting for all activities during period -59. Experience with sporting event -110. Familiarity with location being visited -2In Korea travel or activity:1. Korea Safety Re-brief (using checklist) -5 CONUS Travel:1. Emergency funds available (example: AER) -52. Commercial air versus Space-A Travel -1Other Country Travel:1. Register at local embassy -52. Emergency funds available -23. G/S-2 brief tailored to country traveling to -5CONTROL POINTS _____Individual points plus (+) Trip points, minus (-) Control points = Residual Risk _____ pointsCircle Residual Risk Level (after controls):

0-20 21-30 31-40 41+

Low Moderate High Ex High

Age: Under 28 1

Grade: E-1 thru E-6, WO1, CW2, O-1, O-2, 1

Gender: Male – 1

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

1ea2ea3ea

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.

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

112410

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, doesn’t remember what happened Was involved in an alcohol related incident/curfew violation

588

Compulsive Gambling (score only one factor):Loses more than planned Borrows money to gamble Talks about gambling constantly

243

Assessment of Above Risk Factors

Risk Score: 0-6 Low7-11 Medium12-14 High 15+ Extreme

This form is designed to assess a soldier’s risk of a serious incidentSoldiers 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)

Leader’s Name: Date:

If the Soldier is driving review the ASMIS-1 Risk Assessment Tool printout

Leaders Initials:

(STEP 6)Leaders High Risk Assessment Tool

(Completed by leader)This form is designed to assess a soldier’s risk of a

serious incident(Circle appropriate numbers)