CDRL A009 - Accident Report.pdf

G. PREPARED BY

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

16. REMARKS

C. CATEGORY:

TDP ________ TM _______ OTHER

Form Approved OMB No. 0704-0188

15. TOTAL

A. CONTRACT LINE ITEM NO. B. EXHIBIT

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

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

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

7. DD 250 REQ

8. APP CODE

9. STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

H. DATE J. DATEI. APPROVED BY

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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 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 address. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

DIST

22202-4302.

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page of Pages

0003/1003/2003/3003/4003 A/B/C/D/E X

Tunner Loader

A/B/C/D/E009 Accident/Incident Report Mishap Notification and Reporting

DI-SAFT-81563/T OH PWS 5.5.2 AFLCMC/WNZ

DD

N/A B

SEE BLK 16

SEE BLK 16

SEE BLK 16

SEE BLK 16

DCMA 0 1 0

AFLCMC/WNZ 0 1 0

AFLCMC/WNKAC 0 1 0

0 0

Blk 4: Paragraph Requirements, subparagraph 1. Format: add “Electronic submissions are acceptable.”

Blk 7: WAWF ACCEPTOR: The Government will accept the receiving report through WAWF. Contractor shall submit receiving report upon each submission.

Blk 8: When there is “N/A” in block 8, the Government still has the inherent right to disapprove the data item deliverable. The Government shall have 45 days after receipt of Contractor’s submission to approve/disapprove the submission; if approval/disapproval is not received within 45 days of receipt, approval shall be automatic. The Contractor shall have 15 days to respond with a revised submittal for any Government disapprovals.

Blk 9: Distribution Statement: C: Distribution is authorized to US Government agencies and their contractors (administrative or operational use). Other requests for this document shall be referred to AFLCMC/WNZDA.

Blk’s 10-13: Upon qualifying event in accordance with the OH PWS paragraph 5.5.2.

Blk 14:

AFLCMC/WNZ

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

AFLCMC/WNKAC

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

N/A

NSP

BRANTLEY.KYLE.AN

DREW.1545276115

Digitally signed by

BRANTLEY.KYLE.ANDREW.154527611

Date: 2024.02.07 10:58:30 -05'00'

07 Feb 2024 GRIEPENBURG.DE

IDRE.H.1289435464

Digitally signed by

GRIEPENBURG.DEIDRE.H.1289435

Date: 2024.02.16 10:28:58 -05'00'

20240216

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