5100.28 App for Replacement Lost Stolen Destroyed (2).PDF
PDF 35 KB Posted
- Attached to
- Prescription Safety Eyewear
- Solicitation number
- 47QFSA22Q0131
- Issued by
-
GSA Federal Acquisition Service
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Other files
| File | Type | Posted |
|---|---|---|
| PWS - Prescription Safety Eyewear Amend 001 08-24-2022.docx | DOCX document | |
| Instructions to Offeror - RFQ 47QFSA00Q0131 Amend 002 08-30-2022.docx | DOCX document | |
| Instructions to Offeror - RFQ 47QFSA22Q0131 08-08-2022 (3).docx | DOCX document | |
| PWS - Prescription Safety Eyewear Amend 001 08-24-2022.docx | DOCX document | |
| Instructions to Offeror - RFQ 47QFSA00Q0131 Amend 001 08-24-2022.docx | DOCX document | |
| 47QFSA22K0098 BOM PSE 08-05-2022 (2).docx | DOCX document | |
| PWS -Prescription Safety Eyewear 08-08-2022 (1).docx | DOCX document | |
| DD FORM 771-20220411124039 (1).pdf | ||
| Instructions to Offeror - RFQ 47QFSA22Q0131 08-08-2022 (3).docx | DOCX document | |
| Offeror pricing Spreadsheet - Prescription Safety Eyewear 8-5-2022 (1) (1).xlsx | XLSX spreadsheet | |
| 5100.27 Receipt of PSE and Sight Con Prog Policy (1).PDF | ||
| 5100.16 Request PSE (2).pdf |
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FRCSEINST 5103.13
FRCSE 5100/28 (Rev, 8-14) Adobe LiveCycle Designer (electronic) Adobe LiveCycle Designer (printed) All fields required Complete all required fields and mark unused optional fields with N/A.
APPLICATION FOR REPLACEMENT OF LOST, STOLEN OR DESTROYED PRESCRIPTION SAFETY EYEWEAR FRCSE will replace lost or stolen US Government provided equipment issued to employees that was not due to obvious negligence. For prescription safety eyewear (PSE), management must approve replacements BEFORE the process takes place. The replacement of lost, stolen, or destroyed PSE is limited to the cost of basic glasses as required to perform your job. If optional extra-cost optional features are desired for the replacement PSE, THE ADDED COST OF ANY OPTIONAL FEATURES MUST BE BORNE IN FULL BY THE EMPLOYEE, NO EXCEPTIONS.
NOTE: UNTIL REPLACEMENT PSE IS RECEIVED, GOVERNMENT-FURNISHED NON-PRESCRIPTION (PLANO) SAFETY GLASSES OR OTHER SUITABLE EYE PROTECTION FOR THE TASK(S) ASSIGNED SHALL BE WORN OVER PERSONALLY-OWNED CORRECTIVE EYEWEAR.
ATTENTION SIGNATORIES: Your signatures above: (1) Authorize expenditure of Government funds for the re-issue of government furnished PSE to the above employee, and (2) Certify to the Integrated Support Division (ISD) [Safety] (code 71010) that the statement(s) given above is/are or appear to be honest, true, and accurate to the best of your knowledge, and that a bona fide need for replacement PSE exists.
8. Employee: Return this completed form to the ISD [Safety] (code 71010) to obtain replacement PSE.
2. EMPLOYEE
4. SUPERVISOR
6. BRANCH FOREMAN
7. DIVISION DIRECTOR
9.0.0.2.20120627.2.874785
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