6_Solder_Mask_Printer_A002_DI-SAFT-81563_Mishap.pdf

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

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 __X_SAFT_

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

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

Accident/Incident Report

3. SUBTITLE

Mishap Notification and Reporting

4. AUTHORITY (Data Acquisition Document No.)

DI-SAFT-81563 (see NOT 1)

5. CONTRACT REFERENCE

PD para 5.5.4

6. REQUIRING OFFICE

580 SMXS/MXDXAB

7. DD 250 REQ

DD

9. DIST

STATEMENT

REQUIRED

A

10. FREQUENCY

AS REQUIRED

12. DATE OF 1ST SUBMISSION

AS REQUIRED

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

N/A

11. AS OF DATE

SEE BLK 16

13. DATE OF SUBSEQUENT

SUBMISSION

AS REQUIRED

Draft

Final

Reg Repro

16. REMARKS

BLOCK 4: Contractor shall submit a report on ALL mishaps, damage to DoD property, and employee injury, to the Installation Safety Office by phone within four (4) hours after initial notification. Written report shall be submitted within three (3) calendar days of mishap. Electronic submissions are acceptable.

Information that is not available at the time of the initial notification shall be provided within 20 calendar days after the mishap.

Block 7: WAWF ACCEPTOR: The Government will accept the Receiving Report through WAWF. Contractor shall submit Receiving Report upon each submission.

BLOCK 9: Distribution authorized to US Government agencies only. Other requests for this document shall be referred to WR-ALC/SE.

BLOCK 14: Notification to be sent to the following addresses:

WR-ALC/SE, 420 Richard Ray Blvd, Suite 100, Robins AFB GA 31098 WR-ALC/OBCA, 420 Richard Ray Blvd, Suite 100, Robins AFB GA 31098 AFSC/PZIO, 375 Perry Street, Bldg 255, Robins AFB, GA 31098

0 1 0

15. TOTAL 0 1 0

G. PREPARED BY H. DATE J. DATE

DD Form 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED Page _ _ of __Pages

18. ESTIMATED

TOTAL PRICE

17. PRICE

GROUP

INKJET SOLDER

MASK PRINTER

A002

SEE BLK 16

Laura Faith

I. APPROVED BY

8/16/2017