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SOW ATTACHMENT 1: TECHNICAL SUPPORT REQUEST (TSR) FORM

18 May 2020

PART I - ENGINEERING SUPPORT REQUEST (To be completed by SRC Initiator) Administrative Review (JEDMICS ASSISTANCE) Technical Review

1. Control Number: (Provider CAGE #-NSN#-ELIN# )

2. Date:

3. Action Number:

4. Contractor:

5. Point of Contact:

6. NSN:

7. Part Number:

8. Nomenclature:

Request for Engineering Support (CHECK ALL APPLICABLE BLOCKS) Alternate Source:

Alternate Item:

Engineering Change Proposal (ECP) or Request for Deviation (Describe in BLOCK 10) TDP Assistance Distribution Code / Statement Not Assigned Other (Describe in BLOCK 10) Evaluation of Reconditioned / Surplus Offer (Describe in BLOCK 10) Part Number: CAGE:

Contract Number (if available):

Condition: Reconditioned Surplus New Surplus Request Waiver of First Article Test (Describe in BLOCK 10) Other (Describe in BLOCK 10)

10. Contractor’s Supplemental Information / Comments:

11. Enclosures (Identify by number and attach):

PART II - EVALUATION (To be completed by Government IPT) Engineering Support Evaluation (CHECK ALL APPLICABLE BLOCKS) The Alternate Source has been:

Approved (See BLOCK 13 for details) Disapproved (See BLOCK 13 for details) Conditionally Approved (See BLOCK 13 for details) The Alternate Item has been:

Approved (See BLOCK 13 for details) Alternate Item NSN:

T.O. Updates Required: Disapproved (See BLOCK 13 for details) Conditionally Approved (See BLOCK 13 for details) Alternate Item NSN:

T.O. Updates Required:

The ECP / Request for Deviation has been: Approved (See BLOCK 13 for details) Disapproved (See BLOCK 13 for details) Conditionally Approved (See BLOCK 13 for details) TDP Status:

Distribution Code / Statement has been assigned TDP is Not Available TDP is Available in JEDMICS Other (See BLOCK 13 for details) The Recondition / Surplus Offer has been:

Approved (Attach AFMC Fm 813, Surplus Materiel Worksheet) Disapproved (See BLOCK 13 for details) Request for Waiver of First Article Test has been: Approved (See BLOCK 13 for details) Disapproved (See BLOCK 13 for details) Other (See BLOCK 13 for details.)

Returned without action. (See BLOCK 13 for details.)

13. Engineering Supplemental Information / Comments:

14. Enclosures (Identify by number and attach) file_6.png file_7.wmf file_8.png file_9.wmf file_10.png file_11.wmf file_12.png file_13.wmf file_14.png file_15.wmf file_16.png file_17.wmf

Equipment Specialist Coordination (CHECK ALL APPLICABLE BLOCKS AND COMPLETE)

Cataloging Action:

No Cataloging Required Comments (See BLOCK 16 for details)

Cataloging Action Required for Replacement Item: NCC # / NSN: P/N:

I&S - Master NSN:

Change Obsolete NSN to AAC “V”

Item Manager: IM / MDC Code:

Program Manager: PM Telephone:

The following information will be needed: Specification/Data Sheet Government Purpose License Agreement (GPLA) Letter (See BLOCK 17 for details) Commercial Manual (Disk or Electronically) Operational and Maintenance Instructions Illustrated Parts Breakdown (IPB) Other (See BLOCK 16 for details) N/A Engineering Support Evaluation has been concurred. (See BLOCK 16 for details)

Evaluator (Cognizant Equipment Specialist with Approval Authority): ES Signature: ES Code:

*Note* ES must digitally sign the TSR with the understanding that they are responsible and accountable for all cataloging actions and PM & IM have been informed of TSR results.

16. Equipment Specialist Supplemental Information/ Comments:

17. Supplemental Information/ Comments:

GPLA Letter is to be provided by the manufacturer on company letterhead and hand signed. This will allow the Government to use their technical data / manuals by assigning Technical Order (T.O.) numbers and distributing to users.

18. Evaluator (Cognizant Engineer with Approval Authority):

ENG Signature: Date:

*Note* ENG must digitally sign the TSR with the understanding that they are responsible and accountable that all Engineering actions have been completed and verified.