CDRLS.pdf

CONTRACT 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:

TDP TM OTHER

ENVR

X

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

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

GROUP

A011 Environmental Health and Safety Plan

(HSP)

Health and Safety Plan

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE 18. ESTIMATED

TOTAL PRICE

DI-ENVR-81375 Appendix C Insert office symbol_

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

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

DD SEE BLK 16 SEE BLK 16 b. COPIES

8. APP CODE D 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 WR-ALC/GRSA

Block 4 & 5: Contractor format is acceptable.

Contractor shall submit a Safety and Health Plan in accordance with the elements listed in Appendix C.

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

Block 8: Contractor shall submit a Health and Safety Plan within 10 working days after contract award. Written Government approval/comments/disapproval will be within 10 working days after receipt of data. Contractor final submission shall be submitted within 10 working days of receiving Government comments. Approval by the Government is required prior to formal distribution.

Block 9: Distribution authorized to the Department of Defense and U.S.

DoD contractors only. Other requests shall be referred to the contract management team, WR-ALC/GRSKA, 235 Byron St., Suite 19A, Robins

AFB, GA 31098.

Block 14: Procurement Officer(s) e-mail along with Integrated Product Team e-mail distro list will be provided as required. Electronic media shall be provided by CD/DVD media in Microsoft Office compatible format.

235 Byron St.

Suite 19A

Robins AFB,GA

31098-1670

Program Mgr 1 0 1

Primary COR 1 0 1

Alternate COR 1 0 1

(See Blk 16)

DCMA/ACO 0 0 1

Procurement Contract Officer

0 0 1

(See Blk 16)

15. Total 3

0 5

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

DD FORM 1423-1, Feb 2001 Previous editions are obsolete Page 1 of 2 Pages

Rebecca.Taylor Typewritten Text

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.

A012

2. TITLE OF DATA ITEM

Accident/Incident Report

3. SUBTITLE

Mishap Notification and Reporting

4. AUTHORITY (Data Acquisition Document No.)

DI-SAFT-81563

5. CONTRACT REFERENCE

Specify PWS para

6. REQUIRING OFFICE

78 ABW/SE

7. DD 250 REQ

DD

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 Req

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 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 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

78 ABW/SE.

78 ABW/SEG 0 2 0

675 Seventh St.

Bldg. 707 RAFB, Ga. 31098

PCO 0 1 0

Insert address here

COR 1

Insert address here

ACO 1

15. TOTAL 0 5 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

Sherrl.Coonfield

Sherrl.Coonfield Typewritten Text

Sherrl.Coonfield Typewritten Text

Sherrl.Coonfield