Exhibit_J-6_CDRL_A003.pdf

CONTRACT DAT A REQUIREMENTS LIST Form Approved (1 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 of 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 (0704·0188) . Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number . Please do not return your form to the above organization . Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

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

0001,1001,2001,3001,4001 A TOP TM OTHER x

D. SYSTEM/ITEM IE. CONTRACT/PR NO. F.CONTRACTOR

N4523A-l 7-R-0005 TBD

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

A003 INCIDENT REPORT

4 . AUTHORITY (Data Acquisition Document No .) 15. CONTRACT REFERENCE 6. REQUIRING OFFICE

OT-16-20186 SOW SECTION C PSNS&IMF Code 440 7 . DD 250 REQ 9 . DIST STATEMENT 10. FREQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

REQUIRED

ASREQ See Blockl6 DD b . COPIES

8 . APP CODE 11 . AS OF DATE 13. DATE OF SUBSEQUENT a. ADDRESSEE Final NIA SUBMISSION Draft NIA See Blockl6 See Blockl6 Reg Repro

16. REMARKS See Block 16

Block 11 - As of Date: The report shall be submitted until end of each Option Year Period of Performance (POP) end date.

Block 12 & Block 13- Date of First & Subsequent Submission: Contractor shall submit report within (24) hours after an accident resulting in medical treatment of injured personnel.

Block 14 - Distribution: Contractor shall deliver both an electronic copy of the report to the COR and Quality Assurance (QA)/Environmental Safety and Health (ESH) Director. The QNESH Director can be contacted at (360) 476-4326.

15. TOTAL 0 0 0

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Kjiersten McKinney

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 1 Pages

Adobe Professional 8.0

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

CONTRACT DAT A REQUIREMENTS LIST

(1 Data Item)

A. CONTRACT LINE ITEM NO. I B. EXHIBITA

0001 ,1001 ,2001 ,3001 ,4001

I c. CATEGORY:

TOP __ TM __ OTHER x

D. SYSTEM/ITEM IE. CONTRACT/PR NO. ,F.CONTRACTOR

N4523A-17-R-0005 TBD

16. REMARKS (Continued)

DD FORM 1423-1, FEB 2001 Page __ of __ l_Pages

INSTRUCTIONS FOR COMPLETING DD FORM 1423

(See DoD 5010. 12-M for detailed instructions.}

FOR GOVERNMENT PERSONNEL

Item A . Self-explanatory.

Item B. Self-explanatory.

Item C. Mark (X) appropriate category: TOP - Technical Data Package;

TM - Technical Manual; Other - other category of data, such as "Provisioning, ""Configuration Management," etc .

Item D. Enter name of system /item being acquired that data will support.

Item E. Self-explanatory (to be filled in after contract award).

Item F. Self-explanatory (to be filled in after contract award).

Item G. Signature of preparer of CORL.

Item H. Date CORL was prepared.

Item I. Signature of CORL approval authority.

Item J. Date CORL was approved.

Item 1. See DoD FAR Supplement Subpart 4 . 71 for proper numbering.

Item 2. Enter title as it appears on data acquisition document cited in Item 4.

Item 3. Enter subtitle of data item for further definition of data item (optional entry) .

Item 4 . Enter Data Item Description (DID) number, military specification number, or military standard number listed in DoD 5010.12-L (AMSDL), or one-time DID number, that defines data content and format requirements .

Item 5. Enter reference to tasking in contract that generates requirement for the data item (e.g., Statement of Work paragraph number) .

Item 6. Enter technical office responsible for ensuring adequacy of the data item .

Item 7. Specify requirement for inspection/acceptance of the data item by the Government.

Item 8. Specify requirement for approval of a draft before preparation of the final data item .

Item 9. For technical data, specify requirement for contractor to mark the appropriate distribution statement on the data (ref. DoDD 5230.24).

Item 10. Specify number of times data items are to be delivered.

Item 11. Specify as-of date of data item, when applicable .

Item 12. Specify when first submittal is required.

Item 13. Specify when subsequent submittals are required , when applicable .

Item 14. Enter addressees and number of draft/final copies to be delivered to each addressee . Explain reproducible copies in Item 16.

Item 15. Enter total number of draft/final copies to be delivered.

Item 16. Use for additional /clarifying information for Items 1 through 15.

Examples are: Tailoring of documents cited in Item 4; Clarification of submittal dates in Items 12 and 13; Explanation of reproducible copies in Item 14.; Desired medium for delivery of the data item .

DD FORM 1423-1 (BACK), FEB 2001

FOR THE CONTRACTOR

Item 17. Specify appropriate price group from one of the following groups of effort in developing estimated prices for each data item listed on the DD Form 1423.

a. Group I. Definition - Data which is not otherwise essential to the contractor's performance of the primary contracted effort (production, development, testing, and administration) but which is required by DD Form 1423.

Estimated Price - Costs to be included under Group I are those applicable to preparing and assembling the data item in conformance with Government requirements, and the administration and other expenses related to reproducing and delivering such data items to the Government.

b. Group II. Definition - Data which is essential to the performance of the primary contracted effort but the contractor is required to perform additional work to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, or quality of the data item.

Estimated Price - Costs to be included under Group II are those incurred over and above the cost of the essential data item without conforming to Government requirements, and the administrative and other expenses related to reproducing and delivering such data item to the Government.

c. Group Ill. Definition - Data which the contractor must develop for his internal use in performance of the primary contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control , and quality of the data item.

Estimated Price - Costs to be included under Group Ill are the administrative and other expenses related to reproducing and delivering such data item to the Government.

d. Group IV. Definition - Data which is developed by the contractor as part of his normal operating procedures and his effort in supplying these data to the Government is minimal.

Estimated Price - Group IV items should normally be shown on the DD Form 1423 at no cost.

Item 18. For each data item, enter an amount equal to that portion of the total price which is estimated to be attributable to the production or development for the Government of that item of data.

These estimated data prices shall be developed only from those costs which will be incurred as a direct result of the requirement to supply the data, over and above those costs which would otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any amount for rights in data. The Government's right to use the data shall be governed by the pertinent provisions of the contract.

DATA ITEM DESCRIPTION

Title: INCIDENT REPORT

AMSC Number: NIA DTIC Applicable: N/ A Preparing Activity: SA

Applicable Forms: NI A

Limitation: Resulting contract from RFP N4523A-17-R-0005

GIDEP Applicable: N/ A Project Number: NIA

Use/relationship: This Report shall be used to track accidents involving contractor personnel, during the performance of assigned tasks, which result in medical treatment.

This DID contains the format, content and intended use information for the data product resulting from the work task described in the contract SOW. This DID is for one-time use for solicitation N4523A-17-R-0005.

Requirements:

1. Format: The report shall be in the contractor's format.

2. Content: The report shall include medically treated injuries sustained by contractor personnel assigned to a contract.

3. The report shall identify the following:

a. Prime Contractor/Subcontractor Company Name

b. Contract Number

c. Delivery Order Number, if applicable

d. Ship Name and Number

e. Location of Event (space, compartment, etc.)

f. Job Order/Work Item Number

g. Name of Contractor Employee(s) Injured

h. Date & Time Injury Occurred

i. Extent of Injury(s) and/or Property Damage

J. Equipment involved

k. Witness( es) and/or Individuals Involved

4. The report shall also provide:

Page 1 of 2 Pages

a. Description of Event(s) Including Occurrences Leading to Accident

b. Short-term and Long-term Corrective Action(s)

c. Root Cause Analysis

ENDDiD

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