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 > 36 yrs +1 RANK: < SPC +5 SGT, 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 +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 ____________ ______________ 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/ Airline Is alcohol involved? Yes____ No____ Battle buddy names(s)________________ Event #2 ______________________________ Transportation method Is alcohol involved? Yes____ No____ Battle buddy names(s) ___________

2. (STEP 4) Trip Risk Assessment (Completed only if traveling outside normal commuting area) Destination: __________________________ Activity/Purpose: _____________ TRANSPORTATION: (to, during and from) Motorcycle +8 POV +5 Train/Bus/Plane/Taxi/Boat +0 If taking POV, driving experience: select one <3 yrs +5 >3 yrs +3 TRIP: select one In Country 5 To CONUS1 To Third Country10 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. 8 2 5 1 13 10 6 2 15 12 7 2 3 2 1 1 >350 350 250 <150 TIME ALLOWED (days) MILESMILES Reason for Travel: select all that apply Emergency Leave4 Party / celebration4 Personal Issue Resolution4 Mid-tour Leave3 Seasonal Conditions (rain, heat, snow) 3 Non-organized Sporting Event3 Shopping2 Friend visit2 Military Sporting Event (participation) 1 Cultural experience1 Family visit1 Other:­­__________________________ Trip Points Total: _____ 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. (STEP 5) Current Risk Level (Individual plus (+) Trip): ____ (circle one) LowModerateHighEx 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/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 POC’s 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 Circle Residual Risk Level (after controls): 0-20 21-30 31-40 41+ LowModerateHighEx High Age: Under 281 Grade: E-1 thru E-6, WO1, CW2, O-1, O-2,1 Gender: Male –1 Marital Status: Single1 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) 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 1 2 4 10 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 588 588 Compulsive Gambling (score only one factor): Loses more than planned Borrows money to gamble Talks about gambling constantly 243243 Assessment of Above Risk Factors Risk Score: 0-6 Low 7-11 Medium 12-14 High 15+ Extreme This form is designed to assess a soldier’s 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) 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)