Attachment 0012 Prohibited Materials Waiver.pdf

UNCLASSIFIED

Attachment 0012

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.

{Name1} {Date1} XXXX, ESOH WG Date

9. Concurrence I concur that use of {prohibited material} as described above under the {Contractor Name} Contract –{Contract Number} is acceptable and justified:

{Name2} {Date2} System Engineer, XXXX Date

{Name3} {Date3} Lead Engineer, XXXX Date

{Name4} {Date4} 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.

{Name5} {Date5}

Project Manager, XXXX Date