CDRL 5 v1.pdf

CONTRACT DATA REQUIREMENTS LIST (1 Data Item) Form Approval 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 this burden estimate or any other aspect of this collection of 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.: 0002

B. EXHIBIT....................................:

C. CATEGORY..............................: OTHER IDIQ Contract

D. SYSTEM/ITEM........: R&D Integrated Space Experiments (RISE)

E. CONTRACT/PR NO.:

F. CONTRACTOR.........:

1. DATA ITEM NO........................: A005

2. TITLE OF DATA ITEM............: SYSTEM SAFETY HAZARD ANALYSIS REPORT (SSHA)

3. SUBTITLE..................................:

4. AUTHORITY.............................: DI-SAFT-80101B

5. CONTRACT REFERENCE......:

6. REQUIRING OFFICE..............: AFRL/RVE

7. DD250 REQ................................: LT

8. APP CODE.................................: A

9. DIST. STATEMENT REQUIRED......: (See 16)

10. FREQUENCY......................................: (See 16)

11. AS OF DATE........................................: (See 16)

12. DATE OF FIRST SUBMISSION: (See Block 16)

13. DATE OF SUBSEQUENT SUBM.: (See Block 16)

14. DISTRIBUTION

A. ADDRESSEES

B. COPIES

Refer to Block 16 and Task Orders of the RISE contract for additional distribution instructions. Instructions vary per Task Order and provide additional guidance in regard to the requirements for Blocks 14A and 14B of this

CDRL

DRAFT FINAL

AFRL/RVKI LT

AFRLRVE COR/ 1

15. TOTAL: 1

16. REMARKS

Blk 4: Tailoring :

- Contractor format is encouraged. All data should be presented in a format that facilitates interpretation.

Blk 9: All documentation shall be marked IAW DoDD 5230.24 with the following distribution statement: “DISTRIBUTION STATEMENT E. Distribution authorized to DoD Components only; Critical Technology and Contractor Performance Evaluation, 2Aug11. Other requests for this document shall be referred to the Air Force Research Laboratory/ RVK, RISE Contracting Officer Representative (COR), 3550 Aberdeen Ave SE, Kirtland AFB, NM 87117-5776.”

EXPORT CONTROL WARNING: All technical data shall be marked as follows: “WARNING — This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C. Sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C. App 2401 et seq. Violations of these export laws are subject to severe criminal penalties. Disseminate in accordance with provisions of DoD Directive 5230.25.”

Blk 10: Once per task order

Blk 11-12: The draft SSHA shall be delivered within 15 calendar days after initial task order award. The government will review and provide comments to the draft plan within 15 calendar days after receipt of the draft. Upon receipt of the comments, the contractor shall take no more than 15 calendar days to incorporate all required changes and deliver the final version of the report.

Blk 13: Not applicable – one submission per task order IAW Blk 10-12 tailoring instructions.

Note: Unencrypted E-mail transmittal is not permitted.

17. PRICE GROUP: 18. ESTIMATED TOTAL PRICE :

G. PREPARED BY: Stephen L. Lucero, AFRL/RVEI I. APPROVED BY: R. S. Brown

H. DATE: 18 Jan 17 J. DATE:

DD Form 1423-1, SEP 97 (EG) (Computer Generated) PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 1 Pages

DRAFT