RFP_Attachment_12_CDRL_A047_Mishap_Notification_and_Reporting.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved (7 Data Item) 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 01 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 (0704~01881. Respondents should be aware that notwithstanding any other provision of law. no person shall be 5ubjl!ct to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PleaM do not return your form to the above organization. Send completed form to the Government 'lluing Contracting Officer for the Contract/PR No. Ii.ted in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

XSAFTA TOP TM OTHER

D. SYSTEMIITEM liE. CONTRACT/PR NO. F.CONTRACTOR

C2ISR Division (Non-core IPTs/Wrkctrs) PR FX2399-I3-00117 TBD

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

A047 Accidentllncident Report Mishap Notification and Reporting

4. AUTHORITY (Osta Acquisition Document No.! 16. CONTRACT REFERENCE i 8. REQUIRING OFFICE

DI-SAFT·81563 PWS paras 1.3.4.5 and 4.16.2 78 ABW/SE

7.00250 REQ 9. DIST STATEMENT 10. FREQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

DD

REQUIRED

ASREQ ASREQ b. COPIES

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

[ •• ADDRESSEE Final B SUBMISSION DraftN/A SEEBLK 16 ASREQ Reg Repro

16. REMARKS '78 ABW/SE 2

Block 4: Contractor shall submit a report on ALL mishaps, damage to DoD property, and i 675 Seventh Street employee injury, to the Installation Safety Office telephonically within four (4) hours after I Bldg 707 initial notification. Written report shall be submitted within three (3) calendar days of i Robins AFB GA 31098 mishap. Electronic submissions are acceptable. Infonnation that is not available at the time, ofthe initial notification shall be provided within 20 calendar days after the mishap. !WR-ALC/GRCKC 1

235 Byron Street Block 7: Wide Area Work Flow (WA WF) Acceptance: The Government Program Suite 19A Manager or Contracting Officer's Representative will accept the Receiving Report through Robins AFB GA 31098 W A WF. The Contractor shall submit Receiving Report upon each submission.

WR-ALC/GRCBD 1

Block 9: Distribution Statement B: Distribution authorized to US Government agencies 235 Byron Street only. Other requests for this document shall be referred to 78 ABW/SE. Suite 19A

Robins AFB GA 31098 Block 14: Submission via Government approved electronic fonnat (InteIink), in Microsoft (MS) Office 2003, or later. NotifY Government Procurement Contracting Officer (PCO) Intelink--See Blk 16 1 and COR bye-mail of submission into Intelink. The PCO and COR e-mail addresses will be provided in the contract or in a separate contractual memorandum. Contractor shall request access to lntelink site at www.intelink.gov/. Once Intelink access is granted, contractor shall post data to the following URL address:

https:/Iwww.intelink.gov/siteS/isrdcgsaf/OEMJC2ISR%20Division%20Support%20and%

20Services/Fonnsl AIIItems.aspx I

All electronically delivered files shall be screened for virus and delivered virus free.

I

15. TOTAL • 0 S 0

G. PREPARED BY H. DATE I. APPROVE~6'~~~ J.DATE

29 May 12

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~1r~ A.-;ur<llLJOHNSON.DANNY.l. i061 683220 _=~...-l,""""""

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

DO FORM 1423.1, FEB 2001 PREVIOUS EDITION MAYBE USED. Page I or 1 Pages Adobe Professional 8 0