Exhibit_A_CDRLs_23_MAY_2017.pdf

PWS Enclosure (1)

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved 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.

TBD

B. EXHIBIT

A

C. CATEGORY:

TDP _ _ TM _ _ OTHER __ MGMT__

D. SYSTEM/ITEM

AVTB EMS

E. CONTRACT/PR NO.

F. CONTRACTOR

TBD

1. DATA ITEM NO.

A001

2. TITLE OF DATA ITEM

CONTRACTOR’S PROGRESS, STATUS, AND MGMT

REPORT

3. SUBTITLE

MONTHLY STATUS REPORT

4. AUTHORITY (Data Acquisition Document No.)

DI-MGMT-80227

5. CONTRACT REFERENCE

PWS Para 4.1.1

6. REQUIRING OFFICE

AVTB Operations

7. DD 250 REQ

DD

9. DIST

STATEMENT

D

10. FREQUENCY

MTHLY

12. DATE OF 1ST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

See Block 16 Draft Final

Reg Repro

16. REMARKS

Block 4: Contractor format is acceptable.The report shall be delivered in the version of Microsoft Office® Word or Excel used by AVTB. The report shall include, at a minimum:

- Dates and number of hours of emergency medical services performed during the reporting period

- Names of emergency medical personnel who performed services during the reporting period

- Summary of any instances of employee tardiness or absenteeism and planned actions to prevent future occurrences

- Summary of any surge personnel requests issued by the COR or Contracting officer during the reporting period, including o number of surge personnel provided in response to the surge request o dates and number of hours performed

- Summary of incidents requiring emergency medical services during the reporting period

- Certification status, including expiration and renewal dates, of emergency medical personnel and planned actions to renew any expiring certifications or licenses

Block 9: DISTRIBUTION STATEMENT D. Distribution authorized to the Department of Defense and U.S. DoD contractors only (Administrative or Operational Use) (NOV 2016).

Other U.S. requests shall be referred to Amphibious Vehicle Test Branch (AVTB), Attn:

Supply Officer, BLDG 210536 Kraus Street, Camp Pendleton CA 92055-5217.

Block 12, 13: The report shall be delivered no later than 1400 on the 10 th of each month.

Block 14: Distribution shall be made via electronic mail. All submissions shall be in the current version of Microsoft Office® Word used by AVTB.

COR 1

15. TOTAL --------- 1

G. PREPARED BY

C. W. Burkhart

H. DATE

13 MAR 2017

I. APPROVED BY

Capt. W.M. Lambuth

J. DATE

13 MAR 2017

DD Form 1423-1, FEB 2001 (EG) Previous editions are obsolete Page _1_ of _1_ Pages

PWS Enclosure (1)

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved 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.

TBD

B. EXHIBIT

A

C. CATEGORY:

TDP _ _ TM _ _ OTHER __ MGMT__

D. SYSTEM/ITEM

AVTB EMS

E. CONTRACT/PR NO.

F. CONTRACTOR

TBD

1. DATA ITEM NO.

A002

2. TITLE OF DATA ITEM

CONTRACTOR’S PROGRESS, STATUS, AND MGMT

REPORT

3. SUBTITLE

INCIDENT REPORT

4. AUTHORITY (Data Acquisition Document No.)

DI-MGMT-80227

5. CONTRACT REFERENCE

PWS Para 4.1.2

6. REQUIRING OFFICE

AVTB Operations

7. DD 250 REQ

DD

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

See Block 16 Draft Final

Reg Repro

16. REMARKS

Block 4: Contractor format is acceptable.

The report shall be delivered in the version of Microsoft Office® Word or Excel used by AVTB. The report shall include, at a minimum, a description of the injury, when did the injury occur, where did the injury occur, and why the injury might have occurred.

For Example: If a Marine cuts his hand, then report states: At 1000 20161024 a Marine cut his hand performing X activity. He was located on AVTB’s ramp. The medical support I provided was this…. Recommend Marine see local BAS for follow up apt tomorrow or not…etc.

Block 9: DISTRIBUTION STATEMENT D. Distribution authorized to the Department of Defense and U.S. DoD contractors only (Administrative or Operational Use) (NOV 2016).

Other U.S. requests shall be referred to Amphibious Vehicle Test Branch (AVTB), Attn:

Supply Officer, BLDG 210536 Kraus Street, Camp Pendleton CA 92055-5217.

Block 12, 13: The report shall be delivered no later than 0800 the following business day.

Emergency medical treatment provided should be verbally briefed to the senior Government personnel at the site of the incident, followed by a written report the next business day.

Block 14: Distribution shall be made via electronic mail. All submissions shall be in the current version of Microsoft Office® Word used by AVTB.

COR 1

15. TOTAL --------- 1

G. PREPARED BY

C. W. Burkhart

H. DATE

23 MAY 2017

I. APPROVED BY

Capt. W.M. Lambuth

J. DATE

23 MAY 2017

DD Form 1423-1, FEB 2001 (EG) Previous editions are obsolete Page _1_ of _1_ Pages