CDRLs_A002-_Mishap.pdf

PDF 203 KB Posted

Attached to
Robotic Grit Blast Booth System Federal contract opportunity
Solicitation number
F3QCCM8079A002
Issued by
Department of the Air Force Materiel Command Lifecycle Management Center Robins Air Force Base

About this file

CDRL A002

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Text version

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__

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

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

ACCIDENT/INCIDENT REPORT

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-SAFT-81563/T NOT 1

5. CONTRACT REFERENCE

PD paras 7.4.C

6. REQUIRING OFFICE

WR-ALC/SE

7. DD 250 REQ

NO

9. DIST

STATEMENT

REQUIRED

B

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

BLOCKS 4,11: Contractor shall submit a report on ALL mishaps,damage to DoD property, and employee injury, to the Installation Safety Office telephonically 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 9: Distribution authorized to US Government agencies only. Other requests for this document shall be referred to WR-ALC/SE.

0 1

15. TOTAL 0 3 0

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

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

18. ESTIMATED

TOTAL PRICE

17. PRICE

GROUP

L8WC14

A002

WR-ALC/SE

420 Richard Ray Blvd, Ste 100 Robins AFB, GA 31098

1 1 Kayla Dunbar 09/06/2017

0 1WR-ALC/OBCA

420 Richard Ray Blvd, Ste 100 Robins AFB, GA 31098

0 1AFSC/PZIO,

375 Perry St, Bldg 255, Robins

AFB, GA 31098

Christine L. Clark 06 Mar 18

1461347777C Typewritten Text

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