CDRL A004 -04 Jun 25.pdf

End itemCONTRACT DATA REQUIREMENTS LIST Form Approved (1 Data Item) OMB No. 0704-0188

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 thus burden estimate or any other aspect of this collection o f information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget. Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. 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:

0005/0010 A TDP TM OTHER SAFT

D. SYSTEM ITEM F. CONTRACTOR

WIU

E. CONTRACT/PR NO.

TEMP-25093004 TBD

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE 17. PRICE

GROUP

A004 Accident/Incident Report

5. CONTRACT REFERENCE 6. REQUIRING OFFICE 18. ESTIMATED

TOTAL PRICE

DI-SAFT-81563/T SEE BLK 16 AFLCMC/WIU

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

10. FREQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

LT SEE BLK 16 SEE BLK 16 b. COPIES

8. APP CODE C 11. AS OF DATE 13. DATE OF SUBSEQUENT SUBMISSION a. ADDRESSEE DRAFT FINAL

A SEE BLK 16 SEE BLK 16 Reg Repr o

16. REMARKS See Blk 16 for email addresses

1 1

BLK5: PWS Para 10.3

BLK 7: Submit final DD Form 250 for Delivery Order DoDAAC, via iRAPT (formally WAWF), to attention: IAW Delivery Order Task Order Description to collectively account for data previously submitted. The Government will approve/disapprove within 30 workdays (business) days of receipt.

BLKs 8, 10-13: The Contractor shall submit the report 10 business days after completion of review,,study, analysis, etc. The Government Program Manager will approve/disapprove within 5 business days. If corrections/changes are required, the Government will submit within 5 days of review. After receipt of corrections/changes from the Government, the Contractor shall incorporate comments and resubmit within 5 business days.

BLK 9: Distribution authorized to U.S. Government Agencies and their contractors (Administrative or Operational use). Other request for this document shall be referred to AFLCMC/WIUBB).

BLK 14: Submit a digital copy in Microsoft® Office® or an Adobe® Portable Document Format (PDF) format.

Email Addresses:

Shundrenic.zanders@us.af.mil Alton.Hayes.3.ctr@us.af.mil

15. Total

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

Shundrenic Zanders 02 Jun 2025 Shundrenic Zanders 02 Jun 2025

DD FORM 1423-1, Feb 2001 Previous editions are obsolete Page 1 of 1 Pages