DD_Form_1423-1_rev_1.pdf

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved 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

A

C. CATEGORY:

TDP _ _ TM _ __ OTHER

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

1. DATA ITEM NO.

A001

2. TITLE OF DATA ITEM

Technical Report - Study/Services

3. SUBTITLE

Medical Evaluation

4. AUTHORITY (Data Acquisition Document No.)

DI-MISC-80508B

5. CONTRACT REFERENCE

SOW Para 5.0

6. REQUIRING OFFICE

NUWCDIVNPT Code 1051

7. DD 250 REQ

LT

9. DIST STATEMENT

REQUIRED

F

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

SEE BLK 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

N/A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

SUBMISSION N/A

Draft Final

Reg Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT F: Further distribution only as directed by Commander, Naval Undersea Warfare Center Division, Newport (Code 105) or higher DoD authority; 12 February 2015.

BLOCK #9: The following information is specifically included in amplification of Block #9, Distribution Statement selected:

Distribution Statement paragraphs are required in addition to CLASSIFICATION markings of the data.

DISTRIBUTION STATEMENT F: Further dissemination only as directed by Code 105, Naval Undersea Warfare Center Division, Newport, Newport, RI, Date Data generated, or higher DoD Authority under Specific Authority – Privacy Act of 1974.

EXPORT CONTROL WARNING NOTICE:

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 sever criminal penalties. Disseminate in accordance with provisions of DoD Directive 5230.25.

Blocks 12 and 13: The contractor shall submit each each report within 5 days after the evaluation occurs.

NOTE: Contractor's format is acceptable.

Report may be transmitted electronically using the AMRDEC Safe Access File Exchange (SAFE) at https://safe.amrdec.army.mil/SAFE/. This site requires a specific email address to which to send documents - use ellen.vadney@navy.mil.

Additional options that should be selected when using SAFE include:

- Encrypt email message when possible

- Require CAC for Pick-up

Mark "FOUO" and "Protected by Privacy Act" under the Other drop down list.

Code 1051 0 1 0

NUWCDIVNPT

15. TOTAL ------------> 0 1 0

G. PREPARED BY

E. C. Vadney

H. DATE

2/12/2015

I. APPROVED BY J. DATE

17. PRICE

GROUP

18. ESTIMATED

TOTAL PRICE

DD Form 1423-1, FEB 2001

PREVIOUS EDITION MAY BE USED

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