C04.0 Attachment J-4 CDRLs & DIDs.pdf

For the best experience, open this PDF portfolio in

Acrobat X or Adobe Reader X, or later.

Get Adobe Reader Now!

http://www.adobe.com/go/reader

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

16. REMARKS (Continued)

DD FORM 1423-1, FEB 2001 Page of Pages

INSTRUCTIONS FOR COMPLETING DD FORM 1423

(See DoD 5010.12-M for detailed instructions.)

FOR GOVERNMENT PERSONNEL

Item A. Self-explanatory.

Item B. Self-explanatory.

Item C. Mark (X) appropriate category: TDP - Technical Data Package;

TM - Technical Manual; Other - other category of data, such as "Provisioning,""Configuration Management," etc.

Item D. Enter name of system/item being acquired that data will support.

Item E. Self-explanatory (to be filled in after contract award).

Item F. Self-explanatory (to be filled in after contract award).

Item G. Signature of preparer of CDRL.

Item H. Date CDRL was prepared.

Item I. Signature of CDRL approval authority.

Item J. Date CDRL was approved.

Item 1. See DoD FAR Supplement Subpart 4.71 for proper numbering.

Item 2. Enter title as it appears on data acquisition document cited in Item 4.

Item 3. Enter subtitle of data item for further definition of data item (optional entry).

Item 4. Enter Data Item Description (DID) number, military specification number, or military standard number listed in DoD 5010.12-L (AMSDL), or one-time DID number, that defines data content and format requirements.

Item 5. Enter reference to tasking in contract that generates requirement for the data item (e.g., Statement of Work paragraph number).

Item 6. Enter technical office responsible for ensuring adequacy of the data item.

Item 7. Specify requirement for inspection/acceptance of the data item by the Government.

Item 8. Specify requirement for approval of a draft before preparation of the final data item.

Item 9. For technical data, specify requirement for contractor to mark the appropriate distribution statement on the data (ref. DoDD 5230.24).

Item 10. Specify number of times data items are to be delivered.

Item 11. Specify as-of date of data item, when applicable.

Item 12. Specify when first submittal is required.

Item 13. Specify when subsequent submittals are required, when applicable.

Item 14. Enter addressees and number of draft/final copies to be delivered to each addressee. Explain reproducible copies in Item 16.

Item 15. Enter total number of draft/final copies to be delivered.

Item 16. Use for additional/clarifying information for Items 1 through 15.

Examples are: Tailoring of documents cited in Item 4; Clarification of submittal dates in Items 12 and 13; Explanation of reproducible copies in Item 14.; Desired medium for delivery of the data item.

FOR THE CONTRACTOR

Item 17. Specify appropriate price group from one of the following groups of effort in developing estimated prices for each data item listed on the DD Form 1423.

a. Group I. Definition - Data which is not otherwise essential to the contractor's performance of the primary contracted effort (production, development, testing, and administration) but which is required by DD Form 1423.

Estimated Price - Costs to be included under Group I are those applicable to preparing and assembling the data item in conformance with Government requirements, and the administration and other expenses related to reproducing and delivering such data items to the Government.

b. Group II. Definition - Data which is essential to the performance of the primary contracted effort but the contractor is required to perform additional work to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, or quality of the data item.

Estimated Price - Costs to be included under Group II are those incurred over and above the cost of the essential data item without conforming to Government requirements, and the administrative and other expenses related to reproducing and delivering such data item to the Government.

c. Group III. Definition - Data which the contractor must develop for his internal use in performance of the primary contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, and quality of the data item.

Estimated Price - Costs to be included under Group III are the administrative and other expenses related to reproducing and

d. Group IV. Definition - Data which is developed by the contractor as part of his normal operating procedures and his effort in supplying these data to the Government is minimal.

Estimated Price - Group IV items should normally be shown on the DD Form 1423 at no cost.

Item 18. For each data item, enter an amount equal to that portion of the total price which is estimated to be attributable to the production or development for the Government of that item of data.

These estimated data prices shall be developed only from those costs which will be incurred as a direct result of the requirement to supply the data, over and above those costs which would otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any amount for rights in data. The Government's right to use the data shall be governed by the pertinent provisions of the contract.

DD FORM 1423-1 (BACK), FEB 2001

data_item: A005 title: GAS FREE PROGRAM REPORT sub:

auth: DI-MGMT-82093 ref: SOW PARAGRAPH 6.27 req_ofc: PSNS and IMF CODE 101 dd250: DD appcode: N/A dist: D freq: ASREQ asof: 26SEPT05 firstsub: See Block16 subsub: ASREQ addressee1: See Block 16 draft1:

reg1: 1 repro1:

addressee2:

draft2:

reg2:

repro2:

addressee3:

draft3:

reg3:

repro3:

addressee4:

draft4:

reg4:

repro4:

addressee5:

draft5:

reg5:

repro5:

addressee6:

draft6:

reg6:

repro6:

addressee7:

draft7:

reg7:

repro7:

addressee8:

draft8:

reg8:

repro8:

addressee9:

draft9:

reg9:

repro9:

addressee10:

draft10:

reg10:

repro10:

addressee11:

draft11:

reg11:

repro11:

addressee12:

draft12:

reg12:

repro12:

addressee13:

draft13:

reg13:

repro13:

addressee14:

draft14:

reg14:

repro14:

addressee15:

draft15:

reg15:

repro15:

addressee16:

draft16:

reg16:

repro16:

addressee17:

draft17:

reg17:

repro17:

addressee18:

draft18:

reg18:

repro18:

addressee19:

draft19:

reg19:

repro19:

addressee20:

draft20:

reg20:

repro20:

addressee21:

draft21:

reg21:

repro21:

addressee22:

draft22:

reg22:

repro22:

addressee23:

draft23:

reg23:

repro23:

addressee24:

draft24:

reg24:

repro24:

addressee25:

draft25:

reg25:

repro25:

addressee26:

draft26:

reg26:

repro26:

addressee27:

draft27:

reg27:

repro27:

addressee28:

draft28:

reg28:

repro28:

addressee29:

draft29:

reg29:

repro29:

addressee30:

draft30:

reg30:

repro30:

addressee31:

draft31:

reg31:

repro31:

addressee32:

draft32:

reg32:

repro32:

addressee33:

draft33:

reg33:

repro33:

addressee34:

draft34:

reg34:

repro34:

addressee35:

draft35:

reg35:

repro35:

addressee36:

draft36:

reg36:

repro36:

addressee37:

draft37:

reg37:

repro37:

addressee38:

draft38:

reg38x:

repro38:

total_draft: 0 total_reg: 1 total_repro: 0 remarks: Block 9 - DISTRIBUTION D: Distribution authorized to Department of Defense and US DoD contractors only (administrative or operational use) (As of 7-8-2016). Other requests for the document shall be referred to PSNS and IMF, 1400 Farragut Ave. Bremerton WA, 98314.

Block 12 - Date Of First Submission: Contractor shall provide at time of delivery order (DO) award.

Block 14 - Distribution: Contractor shall deliver a copy of the Gas Free Program Report to the PSNS&IMF supervisor and the Contracting Officer's Representative (COR).

group:

total_price:

prep_name: Kjiersten McKinney line_item: CLIN XXXX exhibit: A xtdp: Off xtm: Off othercat: X system: SHOP SUPPORT ctr_no: N4523A-22-D-XXXX contr: TBD remarksb:

Page2: 2

Reset:

2022-01-19T14:09:31-0800

MCKINNEY.SUSAN.K.1128778795

prep_date: 22JAN19 app_by: Kjiersten McKinney

2022-01-19T14:10:47-0800

MCKINNEY.SUSAN.K.1128778795

app_date: 22JAN19

Page: 1 of_pages: 2 app: Adobe Professional 8.0

DATA ITEM DESCRIPTION

Title: GAS FREE PROGRAM REPORT

Number: DI-MGMT-82093 Approval Date: 20161208

AMSC Number: N9754 Limitation: N/A

DTIC Applicable: No GIDEP Applicable: No

Preparing Activity: SH Project Number: MGMT-2017-001

Applicable Forms: N/A

Use/Relationship: The Gas Free Program Report will provide the Government with proof of the

Contractor’s confined space entry/gas free certification processes and qualified personnel, including sub-contractors.

This DID contains the format and content preparation instructions for the data product generated by the specific and discrete task requirements as delineated in the contract.

Requirements:

1. Format. The Report shall be in contractor’s format.

2. Content. The Gas Free Program Report shall contain the following Sections:

2.1 Objective.

2.2 Background.

2.3 Assignment of Responsibility for:

a. Employer

b. Program Manager

c. Entry Supervisors

d. Attendants

e. Rescue Team

f. Entrants/Affected Employees

2.4 Training:

a. Training Frequency

b. General Training

c. Specific Training

d. Verification of Training

2.5 Identification of Hazards and Evaluation of Confined Spaces:

a. Survey

b. Hazard Reevaluation

c. Pre-Entry Hazard Assessment

d. Hazard Controls

Source: https://assist.dla.mil -- Downloaded: 2021-12-09T16:32Z Check the source to verify that this is the current version before use.

DI-MGMT-82093

2.6 Entry Permits:

a. Key Elements of Entry Permits

b. Permit Scope and Duration

2.7 Entry Procedures:

a. Prior to Entry

b. Opening a Confined Space

c. Atmospheric Testing

d. Isolation and Lockout/Tagout Safeguards

e. Ingress/Egress Safeguards

f. Warning Signs and Symbols

2.8 Maintenance of Safe Conditions:

a. Conditions

b. Tests required

2.9 Emergency Response:

a. Emergency Response Plan

b. Retrieval Systems and Methods of Non-Entry Rescue

2.10 Current Roster of the following personnel:

a. Certified National Fire Protection Association (NFPA) Marine Chemists

b. Certified Industrial Hygienists

c. Qualified Competent Persons

End of DI-MGMT-82093

Source: https://assist.dla.mil -- Downloaded: 2021-12-09T16:32Z

Gas Free Program Report

DI-MGMT-82093, dated 08-Dec-2016, has been reviewed and determined to be valid for use in acquisition.

NOTICE OF

VALIDATION

DI-MGMT-82093

NOTICE 1

30-Sep-2021

NOTE: The activities above were interested in this document as of the date of this document. Since organizations and responsibilities can change, you should verify the currency of the information above using the ASSIST Online database at https://assist.dla.mil.

AMSC N/A AREA MGMT

Preparing Activity:

Navy - SH

Source: https://assist.dla.mil -- Downloaded: 2021-12-09T16:35Z https://assist.dla.mil

Source: https://assist.dla.mil -- Downloaded: 2018-04-24T19:15Z

Source: https://assist.dla.mil -- Downloaded: 2018-04-24T19:15Z

Title: Weekly Time Sheet

Number: DI-MGMT-81508B Approval Date: 22 APR 2008 AMSC Number: 9042 Limitation: N/A DTIC Applicable: N/A GIDEP Applicable: None Office of Primary Responsibility: NS/BA02 Applicable Forms: N/A

Use/relationship:

The Weekly Time Sheet shall be used to show actual hours worked and attendance by each contractor for the Contracting Officer.

This Data Item Description (DID) contains format and content preparation instructions for the data product generated by the specific and discrete task requirement as delineated in the contract.

This DID supersede DI-MGMT-81508A.

Requirements:

1. Reference documents: None.

2. Format: Data shall be in contractor’s format unless otherwise specified by the Contracting Officer Representative.

3. Content: The weekly time sheet shall cover the seven day period beginning at 0001 on a Sunday and ending at 2400 on the following Saturday.

3.1 Each contractor assigned to the contract shall be in the report and shall have summarized the preceding weeks time and attendance by:

a. Name duty station/workcenter and dates of reporting period

b. Job number or absence code for hours charged.

c. # of hours (regular).

d. # of hours (overtime).

e. # of shift hours.

f. Time in and time out(e.g. 0700-1530)

3.2 The weekly time sheet shall use unclassified covernames for duty stations, keeping the report unclassified.

Source: https://assist.dla.mil -- Downloaded: 2018-03-13T21:18Z

DI-MGMT-81508B

Hours from Weekly Status report for week ending: YY/MM/DD

DATE TITLE NAME D/L OT HOL VAC S/L OTHER

XXX XXXXXX XXXXXXX XXXXX 32 8ov XXX XXXXXX XXXXXXX XXXXX 36 4np 40nv

32 8np

XXX XXXXXX XXXXXXXXXX

D/L OT HOL VAC S/L OTHER

TOTALS 140 x x x x 20

HOUR CODES

nv – not verified np - no pay ov – overhead ph – personal holiday

4. END OF DI-MGMT-81508B.

Source: https://assist.dla.mil -- Downloaded: 2018-03-13T21:18Z

DATA ITEM DESCRIPTION

Title: INCIDENT REPORT

Number: DI-MGMT-82071

AMSC Number: N9720

DTIC Applicable: No

Preparing Activity: SH

Applicable Forms: N/A

Approval Date: 20161003

Limitation: N/A

GIDEP Applicable: No

Project Number: MGMT-2016-058

Use/Relationship: This DID will be used to describe each accident, electrical shock, and fire that requires medical treatment.

This DID contains the format and content preparation instructions for the data product generated by the discrete task requirement as delineated in the contract.

Format. The report shall be similar to that of Figure 1.

Content. The report shall contain all the information contained in Figure 1.

Source: https://assist.dla.mil -- Downloaded: 2017-03-28T21:48Z

DI-MGMT-82071

Figure 1

INCIDENT REPORT

Report #

INITIAL REPORT REQUESTED UPDATE FINAL REPORT

TYPE OF INCIDENT:

NAME(S) OF INJURED (if applicable):

INCIDENT DATE: TIME: COMPANY:

SUPERVISOR:

LOCATION OF INCIDENT: TYPE OF INJURY OR FIRE:

CAUSE OF INCIDENT: EQUIPMENT INVOLVED:

WORK ITEM NUMBER: CONTRACT NUMBER:

WITNESS AND/OR INDIVIDUALS INVOLVED

NAME(S) DEPT. COMPANY

DESCRIPTION OF INCIDENT

INVESTIGATED BY (NAME): TITLE:

SIGNATURE OF INVESTIGATOR: DATE:

DISPOSITION OF INJURED (if applicable)

IMMEDIATE CORRECTIVE ACTION

FIGURE 1 (continued)

LONG TERM CORRECTIVE ACTION

INVESTIGATED BY (NAME): TITLE:

SIGNATURE OF INVESTIGATOR: DATE:

INCIDENT REPORT

Report #

ROOT CAUSE ANALYSIS

FIGURE 1 (continued) Incident Report Instructions

REPORT NUMBER- Unique tracking number created by contractor

TYPE OF INCIDENT- Injury, fire or near miss

NAME(S) OF INJURED- Self Explanatory

INCIDENT DATE: - Self Explanatory

TIME: - Self Explanatory

COMPANY: - Prime and subcontractors involved

SUPERVISOR – Supervisor of employee(s) involved

LOCATION OF INCIDENT: - Base/Yard, Ship name and hull number, space number and compartment name TYPE OF

INJURY OR FIRE – i.e. broken arm, laceration to head or Class A, B, C fires, smoldering

CAUSE OF INJURY – i.e. Equipment failure, PPE, process

EQUIPMENT INVOLVED – Equipment working on and equipment being used to cause incident WORK

ITEM NUMBER – Work Item being accomplished when incident occurred

CONTRACT NUMBER: - Contract Number assigned by government agency i.e. RMC, Alteration Installation Team

(AIT) Sponsor.

WITNESS AND/OR INDIVIDUALS INVOLVED – Name, company of witnesses and or individuals involved with the incident.

DESCRIPTON OF INCIDENT OR NEAR MISS – Short description of events leading up to incident and extent of injuries and or damage to equipment.

DISPOSITION OF INJURED – i.e. Transported to hospital via ambulance or POV, transported to clinic, released from hospital, name of hospital or clinic, limited duty or loss time (if known).

IMMEDIATE CORRECTIVE ACTION – i.e. Scene/space secured, ship notified (who and when), RMC notified (who and when) clean-up of blood, equipment secured fire debris cleaned up.

INVESTIGATED BY – Self Explanatory.

TITLE – Self Explanatory.

SIGNATURE OF INVESTIGATOR – Self Explanatory.

DATE – Self Explanatory.

LONG TERM CORRECTIVE ACTION – What action(s) were taken so that incident does not reoccur, i.e. training, safety stand down or process/policy change?

ROOT CAUSE ANALYSIS – Process by which you will identify the cause or contributing factors of the incident.

Note: Attach additional information as necessary.

End of DI-MGMT-82071

Title: Programmatic Environmental Safety and Health Evaluation (PESHE) Plan

Number: DI-ENVR-81840 Approval Date: 20111108 AMSC Number: N9215 Limitation: N/A DTIC Applicable: N/A GIDEP Applicable: N/A Office of Primary Responsibility: SH/PMS394 Applicable Forms: N/A

Use/Relationship:

The Programmatic Environmental Safety and Health Evaluation (PESHE) defines how the system implements, follows, maintains, and oversees the environmental planning and compliance with environmental regulations throughout the system service life.

The appropriate programmatic considerations and measures, actions, and management in this regard are described within.

This Data Item Description (DID) contains the format and content preparation instructions for the data product generated by the specific and discrete task requirements as delineated in the contract.

1. Format. The PESHE shall be in contractor’s format.

2. Content. The plan shall contain a title page specifying the following:

a. Title/identification of the system/component/program.

b. Title of Document

c. Contract number

d. Preparing activity or contractor’s title

e. Security classification, when required.

f. Distribution statement

g. Date of generated document

3. The plan shall include:

a. Roles and responsibilities regarding system safety.

b. Contractor’s procedures for ensuring health and safety standards.

Source: https://assist.dla.mil -- Downloaded: 2016-02-01T16:52Z

DI‐ENVR‐81840

c. Whether or not the system is in compliance with applicable federal, state, and local environmental laws and the National Environmental Policy Act (NEPA) throughout the system service life.

d. Identify the necessary steps needed to mitigate a noncompliance system when applicable.

e. Pollution prevention

4. End of DI-ENVR-81840.

Source: https://assist.dla.mil -- Downloaded: 2016-02-01T16:52Z

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the conformance with Government requirements, and the required to perform additional work to conform to Government without conforming to Government requirements, and the contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any data_item: A001 title: CERTIFICATION/DATA REPORT sub: QUALIFICATIONS - INITIAL AND UPDATES auth: DI-MISC-80678 (See Block16) ref: SOW PARAGRAPH 5.1 req_ofc: PSNS and IMF CODE 101 dd250: DD appcode: N/A dist: N/A freq: ASREQ asof: YYMMMDD firstsub: See Block16 subsub: See Block16 addressee1: See Block 16 draft1:

reg1: 1 repro1:

addressee2:

draft2:

reg2:

repro2:

addressee3:

draft3:

reg3:

repro3:

addressee4:

draft4:

reg4:

repro4:

addressee5:

draft5:

reg5:

repro5:

addressee6:

draft6:

reg6:

repro6:

addressee7:

draft7:

reg7:

repro7:

addressee8:

draft8:

reg8:

repro8:

addressee9:

draft9:

reg9:

repro9:

addressee10:

draft10:

reg10:

repro10:

addressee11:

draft11:

reg11:

repro11:

addressee12:

draft12:

reg12:

repro12:

addressee13:

draft13:

reg13:

repro13:

addressee14:

draft14:

reg14:

repro14:

addressee15:

draft15:

reg15:

repro15:

addressee16:

draft16:

reg16:

repro16:

addressee17:

draft17:

reg17:

repro17:

addressee18:

draft18:

reg18:

repro18:

addressee19:

draft19:

reg19:

repro19:

addressee20:

draft20:

reg20:

repro20:

addressee21:

draft21:

reg21:

repro21:

addressee22:

draft22:

reg22:

repro22:

addressee23:

draft23:

reg23:

repro23:

addressee24:

draft24:

reg24:

repro24:

addressee25:

draft25:

reg25:

repro25:

addressee26:

draft26:

reg26:

repro26:

addressee27:

draft27:

reg27:

repro27:

addressee28:

draft28:

reg28:

repro28:

addressee29:

draft29:

reg29:

repro29:

addressee30:

draft30:

reg30:

repro30:

addressee31:

draft31:

reg31:

repro31:

addressee32:

draft32:

reg32:

repro32:

addressee33:

draft33:

reg33:

repro33:

addressee34:

draft34:

reg34:

repro34:

addressee35:

draft35:

reg35:

repro35:

addressee36:

draft36:

reg36:

repro36:

addressee37:

draft37:

reg37:

repro37:

addressee38:

draft38:

reg38x:

repro38:

total_draft: 0 total_reg: 1 total_repro: 0 remarks: Block 4 - Authority: Requirements of DI-MISC-80678 paragraph 10.2.1, 10.2.3, 10.2.4 and

10.3.1 do not apply and shall be deleted. The report shall identify completion of Asbestos Awareness; Occupational Safety and Health (OSH); Lockout/Tag-Plus; Electrical Safety;

Hearing Conservation; Eye Safety Awareness; Fall Protection; Respirator Certification (half or full face); Gas-Free Confined Space Entry; Lead/Cadmium Awareness; Sexual Harrassment; Proper Use of PPE and Hazardous Communications Process and specify Employee Name; Expiration Date; Certifications (copy to be provided); Licenses (copy to be provided) and Medical Limitations.

Block 12 & 13 - Date Of First & Subsequent Submission: The report shall be submitted three (3) business days prior to Period of Performance (POP) start date and arrival of new personnel and as required to ensure personnel qualifications are up to date.

Block 14 - Distribution: Contractor shall deliver an electronic copy of the report to the Contracting Officer's Representative (COR).

group:

total_price:

prep_name: Kjiersten McKinney line_item: CLIN XXXX exhibit: A xtdp: Off xtm: Off othercat: X system: SHOP SUPPORT ctr_no: N4523A-22-X-XXXX contr: TBD remarksb:

Page2: 2

Reset:

2020-06-11T10:21:16-0700

MCKINNEY.SUSAN.K.1128778795

prep_date: 21NOV01 app_by: Kjiersten McKinney

2021-11-01T20:59:48-0700

MCKINNEY.SUSAN.K.1128778795

app_date: 21NOV01

Page: 1 of_pages: 2 app: Adobe Professional 8.0

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the conformance with Government requirements, and the required to perform additional work to conform to Government without conforming to Government requirements, and the contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any data_item: AXXXX title: WEEKLY TIME SHEET sub: ATTENDANCE RECORD REPORT auth: DI-MGMT-81508B ref: SOW PARAGRAPH 5.2 req_ofc: PSNS and IMF CODE 101 dd250: DD appcode: N/A dist: N/A freq: WEEKLY asof: YYMMMDD firstsub: See Block16 subsub: See Block16 addressee1: See Block 16 draft1:

reg1: 1 repro1:

addressee2:

draft2:

reg2:

repro2:

addressee3:

draft3:

reg3:

repro3:

addressee4:

draft4:

reg4:

repro4:

addressee5:

draft5:

reg5:

repro5:

addressee6:

draft6:

reg6:

repro6:

addressee7:

draft7:

reg7:

repro7:

addressee8:

draft8:

reg8:

repro8:

addressee9:

draft9:

reg9:

repro9:

addressee10:

draft10:

reg10:

repro10:

addressee11:

draft11:

reg11:

repro11:

addressee12:

draft12:

reg12:

repro12:

addressee13:

draft13:

reg13:

repro13:

addressee14:

draft14:

reg14:

repro14:

addressee15:

draft15:

reg15:

repro15:

addressee16:

draft16:

reg16:

repro16:

addressee17:

draft17:

reg17:

repro17:

addressee18:

draft18:

reg18:

repro18:

addressee19:

draft19:

reg19:

repro19:

addressee20:

draft20:

reg20:

repro20:

addressee21:

draft21:

reg21:

repro21:

addressee22:

draft22:

reg22:

repro22:

addressee23:

draft23:

reg23:

repro23:

addressee24:

draft24:

reg24:

repro24:

addressee25:

draft25:

reg25:

repro25:

addressee26:

draft26:

reg26:

repro26:

addressee27:

draft27:

reg27:

repro27:

addressee28:

draft28:

reg28:

repro28:

addressee29:

draft29:

reg29:

repro29:

addressee30:

draft30:

reg30:

repro30:

addressee31:

draft31:

reg31:

repro31:

addressee32:

draft32:

reg32:

repro32:

addressee33:

draft33:

reg33:

repro33:

addressee34:

draft34:

reg34:

repro34:

addressee35:

draft35:

reg35:

repro35:

addressee36:

draft36:

reg36:

repro36:

addressee37:

draft37:

reg37:

repro37:

addressee38:

draft38:

reg38x:

repro38:

total_draft: 0 total_reg: 1 total_repro: 0 remarks: Block 12 - Date Of First Submission: The report shall be submitted beginning on the first (1st) business day after the start of the Period of Performance (POP) and is due no later than (NLT) the end of the business day TUESDAY for the prior week.

Block 13 - Date Of Subsequent Submission: The report shall be submitted WEEKLY for each day and shift being supported by contractor personnel during the POP.

Block 14 - Distribution: Contractor shall deliver a copy of the Attendance Records to the Contracting Officer's Representative (COR).

Block 16 - Remarks: Refer to attachment J-2 Attendance Record Report.

group:

total_price:

prep_name: Kjiersten McKinney line_item: CLIN XXXX exhibit: A xtdp: Off xtm: Off othercat: X system: SHOP SUPPORT ctr_no: N4523A-22-X-XXXX contr: TBD remarksb:

Page2: 2

Reset:

2020-06-11T10:21:16-0700

MCKINNEY.SUSAN.K.1128778795

prep_date: 21NOV01 app_by: Kjiersten McKinney

2021-11-01T21:09:08-0700

MCKINNEY.SUSAN.K.1128778795

app_date: 21NOV01

Page: 1 of_pages: 2 app: Adobe Professional 8.0

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the conformance with Government requirements, and the required to perform additional work to conform to Government without conforming to Government requirements, and the contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any data_item: A003 title: INCIDENT REPORT sub:

auth: DI-MGMT-82071 ref: SOW PARAGRAPH 5.3 req_ofc: PSNS and IMF CODE 101 dd250: DD appcode: N/A dist: N/A freq: ASREQ asof: YYMMMDD firstsub: See Block16 subsub: See Block16 addressee1: See Block 16 draft1:

reg1: 1 repro1:

addressee2:

draft2:

reg2:

repro2:

addressee3:

draft3:

reg3:

repro3:

addressee4:

draft4:

reg4:

repro4:

addressee5:

draft5:

reg5:

repro5:

addressee6:

draft6:

reg6:

repro6:

addressee7:

draft7:

reg7:

repro7:

addressee8:

draft8:

reg8:

repro8:

addressee9:

draft9:

reg9:

repro9:

addressee10:

draft10:

reg10:

repro10:

addressee11:

draft11:

reg11:

repro11:

addressee12:

draft12:

reg12:

repro12:

addressee13:

draft13:

reg13:

repro13:

addressee14:

draft14:

reg14:

repro14:

addressee15:

draft15:

reg15:

repro15:

addressee16:

draft16:

reg16:

repro16:

addressee17:

draft17:

reg17:

repro17:

addressee18:

draft18:

reg18:

repro18:

addressee19:

draft19:

reg19:

repro19:

addressee20:

draft20:

reg20:

repro20:

addressee21:

draft21:

reg21:

repro21:

addressee22:

draft22:

reg22:

repro22:

addressee23:

draft23:

reg23:

repro23:

addressee24:

draft24:

reg24:

repro24:

addressee25:

draft25:

reg25:

repro25:

addressee26:

draft26:

reg26:

repro26:

addressee27:

draft27:

reg27:

repro27:

addressee28:

draft28:

reg28:

repro28:

addressee29:

draft29:

reg29:

repro29:

addressee30:

draft30:

reg30:

repro30:

addressee31:

draft31:

reg31:

repro31:

addressee32:

draft32:

reg32:

repro32:

addressee33:

draft33:

reg33:

repro33:

addressee34:

draft34:

reg34:

repro34:

addressee35:

draft35:

reg35:

repro35:

addressee36:

draft36:

reg36:

repro36:

addressee37:

draft37:

reg37:

repro37:

addressee38:

draft38:

reg38x:

repro38:

total_draft: 0 total_reg: 1 total_repro: 0 remarks: Block 12 & Block 13- Date of First & Subsequent Submission: Contractor shall submit report within (24) hours after an accident resulting in medical treatment of injured personnel.

Block 14 - Distribution: Contractor shall deliver both an electronic copy of the report to the COR and Quality Assurance (QA)/Environmental Safety and Health (ESH) Director. The QA/ESH Director can be contacted at (360) 476-4326.

group:

total_price:

prep_name: Kjiersten McKinney line_item: CLIN XXXX exhibit: A xtdp: Off xtm: Off othercat: X system: SHOP SUPPORT ctr_no: N4523A-22-X-XXXX contr: TBD remarksb:

Page2: 2

Reset:

2020-06-11T10:21:16-0700

MCKINNEY.SUSAN.K.1128778795

prep_date: 21NOV01 app_by: Kjiersten McKinney

2021-11-01T21:14:09-0700

MCKINNEY.SUSAN.K.1128778795

app_date: 21NOV01

Page: 1 of_pages: 2 app: Adobe Professional 8.0

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the conformance with Government requirements, and the required to perform additional work to conform to Government without conforming to Government requirements, and the contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any data_item: A004 title: PROGRAMMATIC ENVIRONMENTAL SAFETY AND HEALTH EVALUATION (PESHE) PLAN sub: LEAD COMPLIANCE REPORT - UPDATE auth: DI-ref: SOW PARAGRAPH 5.4 req_ofc: PSNS and IMF CODE 101 dd250: DD appcode: N/A dist: N/A freq: ASREQ asof: YYMMMDD firstsub: See Block16 subsub: See Block16 addressee1: See Block 16 draft1:

reg1: 1 repro1:

addressee2:

draft2:

reg2:

repro2:

addressee3:

draft3:

reg3:

repro3:

addressee4:

draft4:

reg4:

repro4:

addressee5:

draft5:

reg5:

repro5:

addressee6:

draft6:

reg6:

repro6:

addressee7:

draft7:

reg7:

repro7:

addressee8:

draft8:

reg8:

repro8:

addressee9:

draft9:

reg9:

repro9:

addressee10:

draft10:

reg10:

repro10:

addressee11:

draft11:

reg11:

repro11:

addressee12:

draft12:

reg12:

repro12:

addressee13:

draft13:

reg13:

repro13:

addressee14:

draft14:

reg14:

repro14:

addressee15:

draft15:

reg15:

repro15:

addressee16:

draft16:

reg16:

repro16:

addressee17:

draft17:

reg17:

repro17:

addressee18:

draft18:

reg18:

repro18:

addressee19:

draft19:

reg19:

repro19:

addressee20:

draft20:

reg20:

repro20:

addressee21:

draft21:

reg21:

repro21:

addressee22:

draft22:

reg22:

repro22:

addressee23:

draft23:

reg23:

repro23:

addressee24:

draft24:

reg24:

repro24:

addressee25:

draft25:

reg25:

repro25:

addressee26:

draft26:

reg26:

repro26:

addressee27:

draft27:

reg27:

repro27:

addressee28:

draft28:

reg28:

repro28:

addressee29:

draft29:

reg29:

repro29:

addressee30:

draft30:

reg30:

repro30:

addressee31:

draft31:

reg31:

repro31:

addressee32:

draft32:

reg32:

repro32:

addressee33:

draft33:

reg33:

repro33:

addressee34:

draft34:

reg34:

repro34:

addressee35:

draft35:

reg35:

repro35:

addressee36:

draft36:

reg36:

repro36:

addressee37:

draft37:

reg37:

repro37:

addressee38:

draft38:

reg38x:

repro38:

total_draft: 0 total_reg: 1 total_repro: 0 remarks: Block 12 - Date Of First Submission:

Block 13 - Date Of Subsequent Submission:

Block 14 - Distribution: Contractor shall deliver a copy of the Attendance Records to the PSNS&IMF supervisor and the Contracting Officer's Representative (COR).

group:

total_price:

prep_name: Kjiersten McKinney line_item: CLIN XXXX exhibit: A xtdp: Off xtm: Off othercat: X system: SHOP SUPPORT ctr_no: N4523A-22-X-XXXX contr: TBD remarksb:

Page2: 2

Reset:

2020-06-11T10:21:16-0700

MCKINNEY.SUSAN.K.1128778795

prep_date: 21NOV01 app_by: Kjiersten McKinney

2021-11-01T21:20:51-0700

MCKINNEY.SUSAN.K.1128778795

app_date: 21NOV01

Page: 1 of_pages: 2 app: Adobe Professional 8.0