DRAFT - CDRL A006 - Safety Mishap Report-RPA.pdf

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 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 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

RPA

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

A006 Accident/Incident Report Safety Mishap Report

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

DI-SAFT-81563 PWS Para 4.3.5 HQ ACC AMIC/PCE

7. DD 250 REQ 9.DIST STATEMENT

REQUIRED

10. FREQUENCY 12. DATE OF FIRST SUBMISSION

LT

BLOCK 16 BLOCK 16 b. COPIES

8. APP CODE

B

11. AS OF DATE 13. DATE OF SUBSEQUENT

SUBMISSION

a. ADDRESSEE Draft

Final

A

BLOCK 16 BLOCK 16

Reg

Repro

16. REMARKS: HQ ACC AMIC/CO 1

(4) Electronic format shall be compatible with Microsoft Office and will be delivered via the ACC AMIC LAN electronic mail system.

(5) Submit mishap/event information IAW AFI 91-204, Chapter 5 with follow-up information IAW Chapter 6 of this publication. Report shall be submitted using the attached “CDRL A006 ACC Form 164 Ground Mishap Report”

(9) Distribution authorized to U.S. Government agencies only (administrative or operational data, 23 May 07). Other requests for this document shall be referred to HQ ACC AMIC/PKC.

(10), (11), (12), (13) Report shall be submitted NLT COB next business day and updates shall be provided as an addendum to the CDRL.

(15) Repro is electronic mail.

(16) Report should be sent via NIPRNET.

ACC Form 164 Ground Mishap Report.xfdl

HQ ACC AMIC/PCE 1

HQ ACC AMIC/PMA 1

Host Base Safety Office 1

15. TOTAL 4

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