System_Safety_Hazard_Analysis_Report_-_1423-1_(A003).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

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

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

GROUP

System Safety Hazard Analysis Report

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

TOTAL PRICE

DI-SAFT-80101C SOW para 3.3.1.1 AFLCMC/WNZE

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

10. FREQUENCY 12. 14. DISTRIBUTION

DD

DATE OF FIRST SUBMISSION

b. COPIES

8. APP CODE C 11. AS OF DATE 13. DATE OF SUBSEQUENT

SUBMISSION

a. ADDRESSEE DRAFT FINAL

A N/A Reg Repr o

16. REMARKS AFLCMC/

WNZE 0 2 0

BLK 8: The Government will have 30 days after receipt of report for approval or disapproval. The contractor shall have 1 days after receipt of the Government comments to resubmit the report.

BLK 9: DISTRIBUTION STATEMENT C: Distribution authorized to US Government agencies and their contractors. Other requests for this document shall be referred to AFLCMC/WNZE

BLK 14: Documents shall be provided via electronic media utilizing standard Microsoft Office applications. Both hard copies and CD-ROM or DVD shall be submitted to:

Support Equipment & Vehicles Division

ATTN: AFLCMC/WNZE

235 Byron Street, Suite 19A Robins AFB GA 31098-1813 e-mail:

Notification of submission shall be provided to the PCO via e-mail.

15. Total 2

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

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

ROZEBOOM.VICTOR.E.JR.1026994850

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