Attachment_7_-_C-12_OA_Work_Request_Word_Doc_25_Feb15.docx

N00019-15-R-5500 Attachment 7

OVER AND ABOVE (O&A) WORK REQUEST

(Entire package must be submitted by the Contractor)

Date submitted: _______________________ Amount requested: ____________________________

□ Urgent

□ Routine

Proposal Number: __________________________ and/or other CLS Reference Number: ______________________

Contract Number: __________________________ Task Order Number: ____________________________________

Relevant PWS Section(s) & Paragraph(s) _______________________________ CLIN / SubCLIN____________________________________ ACRN: _______________________ CLIN / SubCLIN____________________________________ ACRN: _______________________

Type of Effort: (e.g. ACI, Engine OVHL, Airframe Repair…) ________________________________

□ New

□ Ongoing or In-Work

Check and identify items applicable to the O&A effort:

□ Aircraft Identifiers (Tail & T/M/S): ______________________________ Bureau Number: ____________________

□ Engine Model/Series: ________________ Serial Number: _________________ Engine Position (LH or RH):____

□ Engine Model/Series: _________________ Serial Number: _________________ Engine Position (LH or RH):____

□ Other (describe and include identifiers as applicable): _________________________________________________

Date Discovered: ________________ Provide a brief description of defect and circumstances (attach applicable documents at end):

CLS Project or Maintenance Manager’s REVIEW and APPROVAL prior to submitting O&A Work Request:

Signature: _________________________________ Date: _________________ Name and Title: ___________________________________________________

GOVERNMENT REVIEW / APPROVAL SECTION (review and mark as applicable):

DCMA Industrial Specialist (IS)

Requirement reviewed and is hereby □ Approved □ Rejected □ N/A

Signature: _________________________________ Date: _________________

NOTES: _____________________________________________________________________________________

DCMA Quality Assurance Representative (QAS)

Requirement reviewed and is hereby □ Approved □ Rejected □ N/A

Signature: _________________________________ Date: _________________

Program Management (Technical review conducted by APML and APMSE, as applicable):

Utility Lift Program Manager (PM) □ Concurs □ Does NOT concur

Signature: _________________________________ (electronic signature acceptable) Date: _________________

Contracting Officer Representative (COR):

COR □ Concurs □ Does NOT concur

Signature: _________________________________ (electronic signature acceptable) Date: _________________

Procurement Contracting Officer (PCO) or Contracting Officer or DCMA Administrative Contracting Officer (ACO):

(Submit form with supporting documentation and signatures for Program Management Tool entry.)

Requirement reviewed and is hereby □ Approved □ Rejected

Signature: _________________________________ (electronic signature acceptable) Date: _________________

CONTRACTOR SUPPORTING DOCUMENTATION SECTION

Requested Non-Reporting Time (NRT) in calendar days: __________________

IAW NAVAIR 5252.217-9507: The contractor must provide a description of the over and above work that needs to be performed.

Complete and attach LEGIBLE documentation covering requirement areas, such as:

Proposed total cost breakdown and summary Increased labor hour(s) with breakdown by artisan and work labor category Estimated number of increased labor hours (over and above initial allocation) Increased material / ODC with breakdown to include material list and shipping details (over and above initial allocation) Proposed Corrective Action (cite references to technical publications, etc) Work Area on Aircraft (e.g. Work zone or station, rib #, Area affected, nacelle…) Repair Schedule Timeframe