Attachment 0004 - Request for Use of Prohibited Materials.docx

UNCLASSIFIED

Attachment 0004

Request for Use of Prohibited Materials

04 November 2014

Distribution Statement A – Approved for Public Release; distribution unlimited

(*Distribution Statement A only applies when form is not filled in. Once filled check the Security Class Guide for proper distribution statement/markings)

1. General Information

Requesting Company

Date of Request

Point of Contact

Prohibited material for which waiver is requested

2. Explanation of Use

Instructions: Provide a description of the parts/processes where the prohibited material will be used. Identify all components/parts that will contain the prohibited materials upon vehicle delivery including quantities of these parts. Indicate the specific variant and/or trailer the components/parts are on. Identify whether or not the material will be required for operation or maintenance (including during vehicle rebuild). A separate spreadsheet may be attached listing the specific parts/processes, if needed.

3. Health Hazard

Instructions: Provide an explanation of any health hazards associated with the use or presence of the prohibited material. Include likely routes of exposure to both the operator and the maintainer. Identify if any personal protective equipment (PPE) that would be required as a result of using this material. Include the type of PPE and under what circumstances it would be required (manufacturing, operation, maintenance, etc.).

4. Analysis of Alternatives

Instructions: Identify all alternatives that were considered for the prohibited material. If the alternative is only for specific applications, identify what type of parts it is a potential alternative for. Include explanation as to why each cannot be implemented.

5. Technical Justification

Instructions: Provide technical justification for the use of prohibited material. Explain why it is necessary and why it cannot be eliminated.

6. Program Risk

Instructions: Describe the program risk(s) (cost, schedule, and performance) associated with denial of this request by the Government.

7. Get Well Plan

Instructions: Identify which parts where an alternative may be integrated at a later date. Provide a get well plan explaining how this will be accomplished. Also, indicate which parts you will not be able to eliminate and provide a brief explanation.

The following Sections will be filled in by the Government

8. Environmental Safety and Occupational Health Working Group (ESOH WG) Evaluation/ Recommendation

Instructions: Government ESOH WG will to provide evaluation of the above information and a recommendation to the Product Director/Project Manager regarding approval/disapproval of the prohibited material request.

JPO XXXX, ESOH WG Date Comment by Author: Update with appropriate POCs for approval as needed to be consistent with other program submissions.

9. Concurrence

I concur that use of {prohibited material} as described above under the {Contractor Name} Contract –{Contract Number} is acceptable and justified: Comment by Author: Update with appropriate POCs for approval as needed to be consistent with other program submissions.

JPO XXXX, CHIEF ENGINEER Date

Lead Engineer, XXXX Date

Product Director, XXXX Date

10. Approval

Upon the basis of the findings above, I hereby determine that use of {prohibited material} in the parts identified in Section 1 for {Contractor Name} Contract {Contract Number}is acceptable and justified. Comment by Author: Update with appropriate POCs for approval as needed to be consistent with other program submissions.

Project Manager, XXXX Date

UNCLASSIFIED