Exhibit_A_DD1423.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved I (2 Data I tems} OMB No. 0704-0188

I r,, pi.Cihc r~pon1ng Ouroe.n tor tiltS cotlec f:IOI'l o! iMo rm•uof'l If tstlrnntd to lv«aoe :no I'IO<.Irt p .. re5pot1ae, ii'ICiudil'\9 11.._ "'""' tot,...,.,,...,-"" intlt...CIIUfll , u•c:l'long •••'llnl1 dltl sourc:•U, Qltl'lt m'lg eno m..,t~lng ti'll 0111 ~WNded, end comf4-t~ lnd IIY .. WII\g ,,.. coi'-CtiOn ot ltl.lortneUOtl Send eorn~l\t:l rtta~di"' tho• buuten .._,...,,, , or ..,., otMI' 1Sof'IK1 of this coll.ct.on of informt1lotl, InCluding sugguuons <Jr rllduc:•ng me burden, 10 ,,. D.9tn~nt ot O.lt i'IM, U t C...twe s.,voc;n Cho..Cltlfa te 10/04.()1881 AnpondWIU thoauld be I WI(I thofll tiOI'W>Ih U I "dong M'l'f Ol.h.,. I)I'OV'OIIOI> Ollew, 119 peo~ 1ol~ b t ,..,~hi> 11\Y p .... .tty IQI lt!W!g to C:Oft'&)ly With 1 colte<:toon 0111\IOIMition It It lkH!s nt>l dospfay 1 cunlo\lly yMKJ OMS control nunob••· PI-•• do.o nul rehom yoo.lt fOJm to tt .. • blrYt Ofij.niudon, Sllf'ld ~mpleted form to ltlt Go,..mment ''""'"" Conn•ctlno Otflc• tor,,.. Contoti:I/Pft No. llo t.cJ ;,, Block £

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

CLIN 0002 A TOP X fM _ OTHI:R

D. SYSTEM /ITEM vi E. CONTRACTIPR NO . F. CONTRACTOR MK 30MOD I Projcclor ,low Frequency

I. O ATA ITEM NO. 2. Tlflf OF DATA ITEM 3 SV8Tlll.E

AOO I Te:,t/l nspcction Report Firs1 Articles T es1 Reporls

<4, AVTHOAJTY tt>fl• Ac:qu;Sirion Doc-'-'mlffll No I I !L CONTRACT R~R:RENCE e. R.1!0UIA1NG OffiCE

Dl-NDTI-808091' 2819952- I NAVSEA NUWC KJ'T C423 1 00 250 REO •• DIST STATEMENT 10. fR[QUCNCY 12. DATE OF FIRST SUSMLSSIQN

~ O.STRI BUfiON A£0UIRE00 As Required W/Firsl Art b. COPIES

8 . Af>P COO£ D 11, A$ Of DATf 13. OAU! OF SU8S!QUENT • AOORtSSEE

~---SUBMISSION Orat1 ... Afl)IO

18, REMARKS NUWC KJ>rC423 I DAIA REQUIREMENTS FOR AOO I : NlJWC KPT C421 I

Test and lusp...:ction Repurl:> required for Pirst Aniclc-s. CLIN 0002 a:; per Or:lwings:

281'1'!52·1 l{ev AM, and asso.ciotcd r>mwings, and WS 14 730 ;,llld us specified in Contl"'.tCt Requirements. Test Repol'ts r) rovided arc to no te th..- Serial nluubcrs of c ;.lch Proj ector.

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15. TOTAl 0 I I l DATA i rEMNO 2 TIThE Of OAT A ITEM 3 SUBTITLE

A002 Ccrti ficutcs of Conformance. for 1- irs! Articles, CLIN 0002

4. AUTHORITY I(:Mr• A~rl'()t'l o-t,_.,ot NQ,/ 16. CONTAACT R[f[StENCE 6, REOUIRlNO OFFICE

Of. 'vll SC-8 I 356A 28 19952· I NA VSEA NU\VC KPT C423 --- OAlt OF ~IRST SUBMISSION-7 0 0 250 REO •• 01$T STATEioUNT 10. FR£0.VENCY 12. • •• OISTRliW'nON

R"OUIA;{O

As Required W/FA b, COI'\ES --- 8 . APP COOE D 11. AS OF DATE 13. OATIE OF SU8SEOU£NT t A00R£SSU Fon .. SOOM'\\1?1) . o ... u

1~11ons 16 REMARk S NUWC KPTC42l l DATA R~QUIREMEN.IS ll>r A002: NlJWC KPTC421 I

Ceni ficatesofCOilfOrmancc requin:d for Pirst Articles (A001) CLIN 0002 cb 1)Cr Drawing

2f'119952-1 l~cv AM. associated dra\'.ings and WS 14730 und "" srccificd in Contract

Re~.Juin:mcnts. Ccrt'i ofConform~noc an:: to note Sc•·ial numbers lOr each Project<lr. -- 1-

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I I

1S TOTAL 0 I I I G. PREPARED 6Y H. DATE I. APPROVED 6Y J . OATE

TERRY CLUTTP.R

10 Aug 2015

RAJ IUL PETR IE

10 Aug 2015 I

DO FORM 1423-2. AUG 96 PREVIOUS EDITION MAY BE USEO.

Page L of ~Pages A~ Prott~Ssta'llll 7.0

17. f'fiiCEGROUP

18. ESTIMATED

TOTAl Pfll(:( l7 PRICE CROUP

18. ESTWIATEO

TOTAl PRICE

INSTRUCTIONS FOR COMPLETING DO FORM 1423

/So• DoD 5010. 12·M lor detiu/ed instructions.)

FOR GOVERNMFNT PERSONNEL

hem A. Selt explanatory

Item 8. Self·eKQolanatCKV

Item c. Matk (X} apPfopnatt category TOP • Technical Data Package. TM Tec:hntcai ManuM , OU* other category of da~. such as "'PrOVISKMllrtg."'"'Conhgutltlon Man.gement~ • et,.

Item D. Enter name o r aytle•nJttem bew"U ec:quued that dlt• WIN -· hem E. Setf· exp&lnatory tlo be f~ted W'l i11fl., c:ontr.ct award) llem F. Setf ex.pl .. n4tory flo be f1Ued '"aft., contract award, lle.m C. S.'{J"'<ah•• of ptltf)llrttr of COAL.

hem H. Date COAL wn Pflltp.tted

Item I. Stgnat\we of CDnL 1pproval uuthon1y

Item J. Date COAL wn lpprovod

Item 1. See DoD FAR S4Jf)pfcrnont Subpart 4 , 71 for proper numbeung.

IHUll 2. Cnter IItie as it OJlf)(Jara ou da10 UC(IWSili<HI document c1ted tn II em 4

Item 3, Enter 8Ubtil16 of dAlO 11om to• fur thor dehmt1on ot datn hom (optional onlryl.

Item 4 . Ente r DatA Item Oescrrp1ion (0101 number, rmhta.y specrf~eatron numbor, cu mrtltary stuudurd m.unbur hstcd m DoD 5010 .12·L (AMSOL). or on.;, t rrno 010 number. that defin~ts datB content and format requlrementlt

Item 6. Enter refercrwe to toali.u1g •n contrtct that geMrates reqtnremem lor the data nem (I g., Statement (If Work pauagraph number•.

Item 6. Enter technrcal ollrco rctpons•ble fCH eo.sunng adequacy of the dati uem.

h em 7. Specrfy reqt.Mreroent fOf rnspocuon'IC:ceptance of the data Hem by lhe Gov•rn"*''·

Item 8. Spocrfy requ.ren,cnt fot approval of a draft befOfe preparatJon of the f1n1t datA t1!M

Item 9. f01 techtucal ~11, tpec.tv requ•rement fOt contractOf 10 mart 1hd tf)llfopuatc d•1t.r1buhon atltem~nt on the data bf!'f OoOO 5230 2•1 hem 10. Speotv number of t.mM deta rtems are to be detrvered llem 11 . Speatv as~or datt of data rterr1, wt'M!fl appliCable hem 12. Spec:•fy when f••t IIUbtn!UIIrt reqwred hem 13. Spedfy when aubloquem aubmrttafs ere reqund.

whet'! app .. cable

Item 14. Enter addretJell and number ot draft, hr\aJ c::opNJs to be c:Wiveted to tech addJe~oHe b~our1 roproduabf.e cop.es tn hem 16

Item 16. Enter IOial number o l dreft/hnal cop11!11 to be del•vered hem 16. USG tor ad<flt•onallctaulv•no tnfotmatton tOt Items 1 through 15 E.•uHnpl•l aut: Ttuk>un~ of documenta cited in Item 4; Clanticauon of subm•n•l d11aa in llems 12 end 13.;

Explanatioo of reproducthlo copios rn hem 14.; Oos~red medrum fot dehverv of the datft hem

DD FORM 1423-2 (BACK), AUG 96

FOR THE CONTliACTOR

Item 17. Specrfy appropriate pnce group from one of the folowing gtoups of effc>rl .-. devdop.ng esllmatod pnces fOf each deta trem htcd on the 00 fotm 1423 a Gtoup I. Oer.nition Data whK:h 1s not otherwtse HSentJ•IIo ahe contractor's performance of the pntntry contracted effCHl (production. development. testng and adm.nestratton• but y,-fwch 11 r~red by 00 Form 1423

Esnmated Pnc-e • Costs ro be incJuded under Group ltwe thoM appltc::abhs to prepanng and assembl•ng the data tltm in COnformance With Government reqwr•mtnta, lnd tfMt admlfltstratton and olhc:f expenses related ro reproducil\og and deftve11ng St.ch data Items to the Government.

b. Group II Oehnttron · Data ..,h!Ch t.s eu.enbel to the performance o f the pnmary contracted &ffOtl but the contr•ctOt 11 re(!Uired to perform addtttonal work to conform to Gov\:rnrnettt re(!Uiroments with regard to depth o f cont{tl)1. for'm;.tt, frequency ol submittal, preparation, control. ot quahty of the dara rtem

Estimated Price • Co.scs to be includod undnr Group II arc those incurred over end above lhe cost of tho ossential rla to 110m without confOtming to Governmen t roqwromonte, ond tho admimsttative and oth~r 6Xt>6t\86s w latod to wproduc1no Mtl delivering such dau• item to tho Govornmont.

c . Group Ill. Defi nition • Data whtch tho contractor mutt develop for his internal use in t>etform~mce of tho pnmarv controetoc1 offon and does not require any substantial chango to eonlorm to Government requ11ements wtth regard to depth o f content, format, hequef\Cy o f submrttal. preparatton, control, lind quality of thtt data rtem

Est1matcd Pnoe • Costs to be li\Ciuded undM Group Ill •re tho admJOr$tratrvo and other expensu r~ated to rep.oducmg and delrvcnng such data n em to thoe Government d Group IV. Oehnrhon · Data ......ntc:h 11 developed bv the contr6CtO• IS part of hts nCHmal operanng procedutes and ••• ettou .n supplyang these data to the Government IS mtt\ln\at

E.stunated Poce • Group rv 1tems should normdy be sho-....n on me 00 Form 1423 at no CCHt

Item 18. For each data item. enter an arnount equal to lh.et pc:whon or lhe total pnc:e which is estimated to be allnblll•bte to the producbon or development for me Govet~nl of that ttom or diUol These e.stlf'nated data pnces shall be devetoped onCy from those costs which w~n be •ncurred as a di:rect result of the requwemont to &Upply the data. aver &ltd above those costa which w<H.IId orhetw1se bo rncurTed tn petformance of the contract tf no data wefe requited. The estimated data pnces shall not IOCiudo IHIV amount for righr.s in data Th& Government'• ught to uso th.tt datn shan be governed by the pen.nent provisions of the contlac t

CONTRACT DATA REQUIREMENTS LIST Foun Approved I 12 08l8 {{(Jn)$} OMB No. 0704-0188

Tht po.~bl~ rt porii'IQ buultn lot this coiiKtton oi •'dorm..~t.~n •s esumaltd to .wertge 220 ~'lours pet re:ponse, i.-.:cludin$1 d,. tbwe for revw¥ro';,Q hmuerions, Wll'thrng tliUnno I dtlt IOUtC:tS, gtt....,.-.g • ld m•nl•lnlnll lht cltlt!W<t<,led, oond C:O!I'P .. bn!l ... lid 111-"11'19 Ule col.<:tiOI'I Ol itllotm.wtoOI'\, S.nd C:On'I-M.I II QMding tlwa buiCI«< fl lln'l11lt l,lf ¥1)' oth<w t$pett ol thos coli•chon ol onlo•m•uon, +nek.•chng w<;~;..-tlon• 101 ••d~,M;.,Q ttw """c»n. to l.ht O.pt•t~nt or o.r ...... bett,~I!Vt S.rvoc;" O.ectUf•t• I (0704·018.81. Anpon!Hn111 •holM "- ' " 'lltt the1 notwllhatwlod+ng _..., oiJ• ... prov .. oon o l ~w. no p.raon .., .. bt tiAI..,::t to ~.,. P• n• hy to. lai\nQ to c:Oot~ly woth • COIItoetoon of tnlout\lll iOn 1f rt do.t: not d!IWity t c:~o~n entry "-'kl OMO t<H11tOI '""''I'll>«, Pl .... o.1o n<ol ,,,..,,., you• ' "''"to lhe t bovt OW(,IIII'IiJ• tlor'l. S..nd eom~ttd fotm to lh t Goyemm.ntluuing Contrtc:Cing Ofl~c-tt tor tht Conlt~tiPA No. li• t.cl •• &kxt. f .

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

CLIN 0004, 1002, & 2002 A X 1M OTHER TOP -

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

~1K 30MOO I Proj ector ,Low Frequency

I 1. DATA ITtM NO. 2. TlrLE OF DA TA ITEM 3. SU9llll.E

A003 l esll'lnspection Rcpo11. l,roduction

I

4. AVHIOAITY (~f. AcqviSillort Oocum~r .'lo J 'r CONTAACT Al .. A(NC<

«1 . ACOVIAlNG OUICE

I D I-N DT I-80809B 2819952-1 NA VSEA NUWC KPT C423

715i5Tso REO .. OIST STATEMF.NT- 10, FAEOUEN'CY U . DATE OF FIRST SUBMISSION I--... OISTA18UTION I REQVIR£0

As Requi1·ed WIPROO ---

b. COP.CS

8 . APP COOE D 11. AS OF DATE "· DATE Of SUBSEOUI:NT • · ADDRESSEE Ftn•l I SIA!.MI$$1~ Ouol1 WI ption

, 8. RfMARKS NUWC KI'TC423 I I DA lA REQUIREMENTS ~OR A003 NUWCKPTC42t I

Test and lospec•ion Reports tequired for l1mduction. CI.IN 0004, I 002. & 2002, as per I nrowings: 2819952-1 Rev Af\•1, and associalcd Oruwings. nnd WS 14730 und as S)"'Ccificd in C0111rUCL Requin:111CniS. Te-st RepurlS pruvidctl ure t<) l l<) l c the Serial nun1hCn:> of each . Projector.

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15. TOTAl 0 I I 1 DATA fUM NO. 2. TITLE OF DAT A IUM J. SU8Tn'l.E

A004 Ce11ificutes ofConfOnnauce fOr Productil)n uniL"

6. AUTIK>AITY UJ.r• Acq~~~.S~uon IXH:um«ot No ! 15. CONTRACT RI:HRENCE 8 . REQUIRING Of'I-ICI:

Dl-lviiSC-81356A

7. 00 260 REO 9 . 0 1$1 STATEMENT 10. F-RCOU£NCY 12. OA.lf OF J:IAST $li8Ml$$10t.l 14 , DIS TRIIWTlON

REOUIAEQ

As required With Prod b. COPIES

8. APP CODt D 11. AS Of! OAr~ 13. DATf OF SUBSI!OUENT • · AOOAfS.'SfE fin•l SUBMISSI?~ • Dr•l1 w puons

16. REMARKS NUWC Kf'T C423 I

DAIA REQUIREM ENTS FOR A004 NUWC KJ)T C421 I -

Cenificates of ContOrmMce tequired fOr l,roduction Units (A002) CLIN 0004. 1002. & 2002. as per Drawing 2819952·1 Rc.v AM, uSS<)ciated druwings and WS 147:10 aml ns specified in Contnacl Requirements, Ccrts ofConform;.lnoc are to note Scl'io.\lnu.mbets of ---each Pn)jectM.

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---- I I I

Ul . TOTAL 0 I I I G. PREPARED BV H. DATE I. APPROVED BY J . OAT£

TERRY CLUTTER

10 Aug 2015

RA IIUJ. PETRIE

10 Aug2015 I

DO FORM 1423-2, AUG 96 PREVIOUS EDITION MAY BE USED. Page .1._ o l -'... P•oes M<Cle Pf~$&1Qni117 0

1 7. PAlCE GROUP

HI. (S'rWAT[O 'tOTAL PRIC~ n . PRICE GROUP

••• I:S'nMAri:O TOTAl. PRICE

INSTRUCTIONS FOR COMPLETING DO FORM 1423

(StuJ DoD 50 tO. 12-M lor det~Jiled insttucticns.J

FOR GOVERNMENT PI:RSONNEL

Item A. Self·expl•natory llem 8. Self explanatory hem C. M•rk (X) appropnlllt cat~v TOP Tec:hn~eal Data P.ehge. TM Tec:hntcttl Mdnl•" Otht!t othef categoJy ol data. such a.s •pyov.IMW'IIng. ••tonhguralion Man~gement. • etc hem D. Enter name of tyltom,rlttn btt•ng ac:quued that data .,..il -· hem E. s.lf explanatory Ho be lilted lf'l •ftet contr-.c:t a~Nerdl

Item F. Seff uptaf\.ltory Ho be filled tn aftltf contract award)

Item G. S.gMture of pte:pt(t~r of COAl

Item H. Data ct>Al wa.s propdr~d

Item I. Signature of CORL approval authonty

Item J. Osee COAL wu approved

Item 1. See DoD FAR Supplomont Subpart 4 71 for PfOf)6r rlumbermg.

h em 2. Ento1 t1tle at 11 appotHI on dot• ~cqUISitton document CIIOd 1n Item 4

Item 3. Ente• &ubtillo or d.na 110nl for funhor dtlfltllhOr) of data itom (optional enlly)

Item 4 . Enter Oat• ltflrn Oas.crltlhOn 1010) numbor, m111tary specificbtlon numbor, 01 nulhwv aumdard !lumber hllttd 111 DoD 5010.12·L (AMSOLI. orono tuno 010 numMr, 1h11r defines: data COI'Itcnl and format requirements

Item 5. ~nter refcrcn<:t to "u'k1ny Ul contract thl'lt generates requuement lor tho dalt hem le.g , Stfltemelll of WOfk paragraph numb~)

FOR THE CONTR.I\£!Q!!

Item 1 "]. Spcc:rfy appropnate pnce {P'OUP hom on. or the foUoww-.g:

groups of effort 1n developing est1mated pnces fOt e.lCh d.ltll •t•m l1sted on the DO FOfm 1423 a Gt~ I. Oefintuoo Data whch 1s not otherv.tM uaenulto the c:ontu;ctor's perlonnance of the pnmMY contr.cled effOft {p.-oOJctiOI~. developmenl. tnhng~ and adrnlmstratton) bUI YohiiCh •• re<pred by DO Form 1423.

Estimated Ptiee • Cost& to be Wlduded lfldet Gr~ I .,. those apphcabte to preparing and auon•blrng the data 1tctm "' coolormanoe With GovetM"tent requ~,.,....u,, and the ldm~t'IIStratJon and other expenses related to lt1Wodocll'l1) and delrvet1ng such data 1tems to the Government b . GfOUP II. Oehn1000 • Data wh1c.h 1s eulnt1al to the performanoe of the p111nary contracted effort but lhe contt&et04 it rec,_med to perlorm oddltKltUII work to conform to Govemmeru reqwrement.s w1th regard to depth of con tent, format, freq~ncv of subm1ttal. preparatioo, eooool. or qu•hty or tho data 1tem

Estimated Pnca - Cost9 to be 1ncluded under Group II ere thos.e incuucd over and above the cost of the essential d11U1 1tem withou t coMorming to Govemmenl requ11emuuts, and the a dmilli.Strative and other oJCponsos 1elated to 1eproducino and delivering .such data item to tho Government.

c. Group Ill. Oefini tior'l • Obta whtch the con tractor mutt di~vulop for h1s m ternal use in performance of tho primary con11actod ofton and does not require any substanti;d change to conform to Government requitements with ,.,O~Hd to dopth of coownt, fornu.tt, frequency of submittal, preparatiOft, control. and qual1ty of the date h• m 6. ~nter tKhniClll nfhc:e re~.sihht for cn1.unng item.

adequacy of tho d.,l\1'1 •tem

Item 7, Sp.oc1fy rcqUirtmtnt for ln~pett•on!acc:eptance of the data 1tem by the Government

Item 8. Spec-1fy requ~rwn•nl fOf approval of • draft before preporattOn of lhe fmal data rtem hem 9. For techmc:al data, speafy rOQUIIGfNffit lor contractor to mark the &PPfOoPf"le dostnbuhon statemMlt on me data (ref DoDD 5230 241 hem 10. $peaty ntiii'T\bef of tJrf'et data 11ems are to be -·d hem 11. Specrfy u of date of dltit ttem, v.hen eppbcabfe llef'ft 12. Spec:rfy wMn fnt aubmmll 11 r~•&d

Item 13. Spectfy wfltn IIUbMQuent ~bm!Uillt ate r~rcd whtw' applrc.lble ltern 14. Enter 1ddreUH1 and number of dfafl,ranal cop1os to be delivered to each addte.hM bpl••n roprO+<iuctbl1t eop1es en Item 16.

Item 15. Enter total numbof ol drlh1f1ntl eopiet to be delivered

Item 16. Use for addlt10illll!clauty1ng mlormnon tor Items l thlough 15 Eumplot arc 1 11IOt1ng of docume·rua c1ted rn Item 4; Clenhc:ltlon of submitiAI dates Ill Items 12 lmd 13;

Exl)lanatJon of rCf)•oduc1bte cOJ)iel ul l to-m 14 , De•merl rned.um for dehvery of the dota tlcm

DO FORM 1423·2 !BACK), AUG 96

EstJmared Pnce · COst$ to be lflCiuded under GlotJP Ill aro the admtmsttat1ve and other expenMs rel.aled to reproducing tmd dekvenng such data item to the Govemmtmt.

d. Group IV. Oehn~bon • Data which •s dev~ by the contractOr as pail of tu normal opeiatmg procedur• and hat effou .n $Upptywlg these data to lhe Government •• mnmal

Est,mated Pnce Group IV •terns should normaly be ahown on the DO Form 1423 at no cost.

lle:m 18. FOf each <bta nem, ontef ., amount 8qUcll to that potbof\ ot the total pnce which tS eu.matod 10 bo attnbut6ble to the p.roduclKln or development for the Gov~nment of that 11.,., ol dlta ll\e$e estimated data pnces s.hal be developed ontv from U\OM costs wh1ch wrll be .-.curred n a direct result of the feQUif•"*u to supply th.e data, over and 1bovo thou cost• which woold othe.-w1se be 1ncurrod 10 perfOfmanoo of the conttacl •I no data were reqoited The fl:st.Jmatod data pncos ahaU not lllCtude &ny amount for rights in data. The GQvernmont'a 11ght to u" the dD1il shaft be governed by the pertinent provtsions of the conlfact

DATA TTEM DESCRIPTION

Title: Certificate of Com pi iance Number 01-MISC-!! 13561\ AMSC Number: N9036 D I IC Applicable: 1'-;o Otlice of Primary Responsibility: NA VICP Code 8741 Applicable Forms: N/A

Approval Date: 20071218 Limitation: N/A GIDEP ;\pplicable: No

Usc/Relationship: rhe Cert ificate of Compliance provides certification lrc)ltl the contractor that the materiel supplied is in Cull compliance with nil contract requirements. This DID contains the format, content . and intended use information for the data del iverable required by the contract.

This DID supersedes DI-MISC-81356.

Requirements:

1. Format. TI1e Certificate of Compliance shall he presented in a format similar to that of Figure I.

2. Content. The Ccrti !kate of Compliance shnl l conlllin:

a. Contractor's name.

b. Contractor's address

c. Contractor's phone number.

d. IJate.

c. Contracting A gene) 's name.

1'. Contract Numher.

g. National Stock Number (NSN).

h. Item nomcncln turc.

i. A statement cert ifying that all items furnished on the contract urc in full compliance with all specification and contract requirements.

j. Authorized per..onncl's signature.

k. Authorized personnel's printed name and title.

Page I

01- \IIISC-813S6A

From: ----,,--- ( Contructor ·,, nume)

Address:

--~---------{( 'oii/I'Cic/or 's address)

Phone Number: ______ _ (Contructor '.1 phone number)

Date:

To:

({ 'ontracting Agency)

Contract Number: ______ _

Nat ional Stock Number:

Item Nomenclature: _ __ _

"All items furnished on this contracl arc in full compliance "'ith all specification ami contract requi rcrnents."

(Siwwture of Alllhori:ed Per.\1111111!1

(Printed Name and Title C!/'AIIthorizcd l'<'r.I'Onncl)

Note: I he record ing o f tal se, fictitious, or frm.1dulcnt statements or emries on this document may be puni~hcd as a felony under Federal Statutes.

3. Fnd of01-MISC-81 356A

Pagc 2

Figure 1 -Sample format f(lr a Certificate of Compliance

DATA I~M DESCRIPTION

FOtm .._.,.,., OMB No. 010H IIBB

Pt,OI.Ic r•POf'IIROJ bu'dtn lot tit cdfec»on of ltltOr'm.odOn t. GSJtmaloct to A\4f1Qill 110 ton .,., r~. lndudlno lht 11m1 tor~ w.~ . ....aq ·~ ~ _,.c.n, ;.a&I"IGring and JN"-.~Iino W ~a. dtMdoci. and o:.n-.~ .ncl r~hfii'IO IN QO&Iealon Cll k'lltltmlllot\. S.."IIJ ~~ ttQMditlo ~· bwden OllMn&le 01 .tP; VU. upocs Of lht OOII.aiM 01 irtlom\alian, &nduding ~leW recti.Clil~ W• bl.ltclen, •o Wa~ HMdqualtera SeMcvl, OlrK&Ota!a Jo, Wl)m\l&lon ClPoflllionl and RGCIC)N., 1215 JottAt&On Ol'lil •llJ1M':Iy, ~. 1204. Arlr1glan, VA H2'CFl-4302., al'd iOIN orne. Of~IAJ &1;10el.. Pa,pefWOA.~ Pn:li4o (0"104.(1110), W~ 0C 20SQ).

' · llTlE 2. IOENllRCATIOIO NUUIIER

TEST/INSPECTION REPORT Dl-lro'l'I-808098

3. DESCRIPfiONI?URPOSE

3.1 The cesl/inspection report is used to document test/insp~ction results. find ings. and analyses that will enable the government or concraccing agency to evaluaca complianco with system requirements. pertormance objeccjv~s. s:pecJ.fications. lind cest/inspcction plans.

• Af'PAOVAL OAT£ S. Qr fiCC or PRIMARY RESPONSIDILHY IOPR) ea. one APPUCADLC 6b, OlOCP Af'PuCAOLE (YYI.II.IDOl

970124

F/AFHC- [X)P

l. APVUCAllONAN:n:.RRa.A'llONSHl'P

7. 1 This daca item deocription (DID) conta ins cho format and content proparation inatruc t i ons for the d11tn prod uct genor11ted by ~he spec i f ic nnd discre t e task r equirement

"" delineated jn the contr~tct.

7.2 This DID is applicable to engineering (developmenta l l, preliminary qualification, qualification, and acceptance testing.

7 . 3 Thjs DID super sedeD DI - NOTI - 80809A and DI-H!SC- 80653 .

8 APPflOVAI. UUifATK)N 9a. APPLICIJII.E fOI'MS 110. AMSC NUMDEH

F7 231

10. PfiEPAAA110" INSTflUCllOHS

10.1 EQCD~t · Cont.ract::or format is accep t able. Organi~e r.he infor mation required by parngr aph 10.2 a nd its subparag r a phs undet"standinCJ i n a manner lhllt facilitutes presentation a nd

10 . 2 C:s:mtect. The test/inspection report opplicable.

shall contain the following information. as

10.2.1 c'uu::.c and ti tle gAg £ . The (ollowi ng information shall oppear on the outside front covor and titlo page:

a. Report date .

b. Report nwnber (contractor or government)

c. Contractor's name, address. and commercial and government entity cOda.

d . contract number and contract line i c. em n\ln\be r or sequence number (if applicabl e) .

e. Type of test/in!Jpect.lon (for example, first article occepcance tost, quality conformance inspection, doveloprneneal test. quoli fication r:est, environmental t est) .

f. Identification of item test&d/inspectcd .

g . Oll t.C or period of test/inspcccion.

h. Name and a ddrcao of requiring government activity.

i. Security classification . downgrading end declas sifying information. if applicol>lc .

(Concinuod on page 2)

\l O~STf\i.&UTIOt4 STAltMEWT

DISTRIBUTION STATEMENT A: APPROVED FOR PUBLIC RELEASE; DISTRIBUTION IS UNLIMITED.

DO Form 1664, APR 89 ll511:f)

P4! ot ••o• :...L 01 ..L o

01-NOTt-808098 Block 10. Preparation Instructions (continued)

10.2.2 table of contents. tho table of contents shall idenLi(y the following:

appendix b.

example;

The tit:le and starting page of each major section, poragr11ph, and of the report .

'rhc page, identi(ying number, and title of each illustraLion (for figure, table. photograph, chart. und drawing) .

10 .2.3 Introduc t ion. The introduc1:ion shall include Lho (allowing in(o.r-rnat ion:

l0.2.3.1 Tgst/in?occtjoo gbjcctiyctal . The specific tast/in~pcction objcctivo(s) a~ specified in the contract lasking documenL .

10.2.3.2 Itcmtsl testedtinsgccred . Complete identification o{ ~he itcm(sl tcsLodtinspected including the (ollowing :

a .

b.

c.

d.

model>.

Nomenclature.

National stock number.

Model number. part number. and serial number Type of item !foe ex~lc. prototype, production item. laboratory

c. Serial or lot number.

C. Applicable engineering changes.

g. Production item speciCication, if appl i.cable.

h. Date of manufacture .

10.2.3.3 :resr/josoec tioo rcguiremen tp. Compl ete identification of the test/ inopcction requirements correlated to contractual requirements including the following:

o. Required test/inspection pora~eLers.

b. Performance reQuirements, acceptance or compliance limits. and

~nvironmontal criteria.

10.2.4 SUmmary. Complete test/inspection report suwmary including tho following :

a. A brief discussion o[ the significant test/inspection results.

obucrvation~. conclusions, ond recommondations covered in grcaLer detail olcewhere in the report.

b. Proposed corrective actionc and schedules for £ailurcs or problems cncountcr~d.

c . Idontificat:ion of deviations. departures. or limitations cncounLered. referenced to the contract r-equirements .

d. ~·ables. graphs. illuotrations. or charts as appropriote to simplify Lhe summacy data.

10.2.5 Rr:fe:r;:eoce dpctungots. Complcto identirication of all documento rotorenced in the test/in::;pect:ion roporl including the following, on applicable:

o. Prior tesc/inspection rcporta on the same item .

b . Tost/inspoccion plens and procedure documents.

c. Prior certi(icationG o( compliance.

d . Contractor·s fili de~ignation ~here test/inspection record5 are maintainod.

c . Input paramecers usad .

Tho applic11blc i &sue o£ the documonLs cited therein, including their cpprovcl dateG and dates of any applicable &mendments. notice~. and rovi~iono. shall be oa specified in the controct. .

Pogo 2 o( 4 Pages

Dl-NOTI-80809ll

10.2.6 Body of repgrt. The body of tho teet/inspection report shall be as follows:

10.2 . 6 1 TP~~ equipment identification. Complece idcn~ifica~ion of each item of test equipment used in the test/inspection including Lhc following:

a . Nomenclatura.

b . Model numbor.

c. Serial number.

d. Manufacturer .

o. Calibration status.

!. Accuracy da~a.

9· Comrnenta, if appl1cable.

10 .2.6.2 l'est/inspectigo facility ins t allation and soc- up. Comple~e descr ipLion of the physical set-up used in conducting the test/ i nspection to include the following:

~ - Location or orientation of the item.

b. Locat1on. orienta~ion, or setcings of eest equipment and instrumentation.

c. Loc~tion, orientation. or settingc of sensoro and probes.

d. Location or orientat..i.on of interconncctionn, C8bles, and hoop-ups.

e. Electrical power. pneumatic, fluicJic, and hydraulic requirements .

Drawings. illustrations. and photographs may be used £or clarification.

10.2.6.3 Test/inspecrjon procedures . Comploce descripLion of the procedures used in conducting the test/inopoction to include the following, e . Item selection and inspection LhaL verified auitability lor test/ inspection.

b. Summarized sequence of testing/inspection SLaps, including a description of how Lh~ item wos operated during the tcst/inspcccion, and any control conditions imposed.

10.2.6.4· Test/jnsnecrion results apd anolvois. A copy of all teac/inapection result5 and ana lysic to include Lhe following:

10.2.6.4.1 Recorded dota. The actual recorded data l(or example. log book entr>es. oscillograph5, instrument read1ngs. plotter graphs). If the recorded data is extensive. provide it in an appendix.

10.2.6.4.2 Tesr/inngectigo results. Identification o( all test/ innpection results to includa the fo l lowing :

o. Matrices comparing r~oulcs achieved again~t ccot/insp~ction objectives or requirements .

b. A discussion of cheoe matrices as to their significance. and how they compare to nny prior test/inspections.

c. Calculat10n examples .

d. Discussion of anomalies, deviations. discrep~ncies. or !ailure6, including their impact, causcu, and proposed correct:ivo actions. Tho discussion shall address discrepancies between design roquiremcncs ~nd the tested/inspected configuration.

10.2 . 6 .5 Conclusigng. Test/inspection conclusions distinguished between objcct1ve end subjective to include the following:

~- The effectiveness of the ~es~/inspcction proceduros in mc~suring item porformance.

Page 3 of 4 Pa.g cu

Dl-NDTI- 808098

b. The success or Cailurc of ~he i~am ~o meet required test/inspection o bjectives.

c. Tho need for repeat, addi tional. or alternative tests/ i nspections.

d. The need for item redesign or (urthar devel opment.

e. The need for improved test/inspection proccduren. techniques. or facilities.

f . The adequacy and complc~enesn o( the tcsc/inspcction requirements .

10.2.6.6 Rcco:nmenda t ionn. Recommendalionc DppropriaLo to the test/inspection resu l tn nnd conclusions including the !ollowing:

o . Acceptabi l ity of tho item Lasted/inspect ed (pans or fai l ) .

b. Additiona l testing/inspection required.

c. Redesign required .

d. Problem re·solution.

o. Test/inspection procedure or (ecility i~rovcments.

f. Disposition o! i~cms tested/inspected.

g . Documentation ch~ngcs required.

h. Tcuting/inspcction improvements.

10 .2 . 7 llu tbcnt i CIItioo. The (allowing certifications sholl be included, · ns applicable :

10 . 2 . 7 . 1 ~cntica tjon o( Le1tlior.ogctioo results . A statement chaL lhC test/inspection was performed in accordance with applicable test/inspection plans and procedures. and that the resul ts ore true and accurate. Th~ authent ication shall include the signature of the contractor personnel thaL performed the test(s)/inspection(s}, a contractor reprc~entetivc authorizod to make such certification, and ony government witnesses .

10.2.7.2 Au thentication oC prior y oJ i dotipn. A statemonL jc1cntifying those requirementa not tested/inspected or measured that were previ ously validated .

Include idcnLif ication of the do t a and method employed (or such validacion (for e xample. prior tes~/inspcction. analytical verification. equivolenL item, and so on). The authent ication shall include the signacuro of a contractor representative authori~cd to make such authentication ond any government witness.

1 0 .2 . 7.3 Au tbgot j cntioo of acceptability , A statement thot the item LCGted/ i nspected oither oa s scd or fai l ed i tem acceptability requirements . 'l'his a uthentication shall include the signature of a contractor representative auchori~ed to ~ke such euthentication and any governmcn~ witness .

10.2 . 8 AcQCnd j ces. Appendices shall be used to append detailed ~:est/inspection data, draw1ngs, photographs, or other documentation too voluminous to include in t..hc main body of the report. Th1.s includes:

referenced doc~mentation not previously provided by the government. and tCGt/ ins pection reports from any associated tost/inspeccion aCtlvity that rnoy have performed nome of the teating/ inspecting L·oquiremcnts.

Page 4 of. 4 Pages