TE_41_DAForm4283.pdf

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PREVIOUS EDITIONS ARE OBSOLETE.

FACILITIES ENGINEERING WORK REQUESTFor use of this form, see DA Pam 420-11; the proponent agency is ACSIM.

PART A (See requestor instructions)

CUSTOMER ID

DOCUMENT SERIAL NUMBER

SHORT JOB DESCRIPTION

DATE

DA

MON

YR

INSTALLATION ABBREVIATION OF FACILITIES

BUILDING/FACILITY NUMBERS

REMARKS

INSTALLATION NAME

CUSTOMER NAME

POC NAME

POC PHONE NUMBER

PART B(Approving Official Only)

APD LC V1.00ES

DA FORM 4283, NOV 2018

APPROVAL ACTION CODE:

WORK REQUEST PRIORITY:

PROGRAM INDICATOR CODE:

DATE

DA

MON

YR

SPECIAL INTEREST CODE:

ESTIMATED WORK START DATE:

ESTIMATED WORK COMPLETION DATE:

DATE

DA

MON

YR

DATE

DA

MON

YR

APPROVAL ACTION

ENVIRONMENTAL IMPACT

YES

NO

ENVIRONMENTAL CONSIDERATION

EIS / EIA INITIATED

EIS / EIA COMPLETED

APPROVED

DISAPPROVED

IN-HOUSE

SELF-HELP

CONTRACT

TROOP

WORK TO BE PERFORMED

SOURCE OF FUNDS

ACCOUNT PROCESSING CODE

WORKCLASS

APPROVAL AMOUNTS

FUNDED

UNFUNDED

TOTAL

DIRECT

AUTOMATIC REIMBURSEMENT

FUNDED REIMBURSEMENT

AUTHORIZED REQUESTOR SIGNATURE

DESIGN APPROVAL SIGNATURE

APPROVAL AUTHORITY SIGNATURE

WORK DESCRIPTION (Description and justification of work request) DESIGN APPROVAL (Please type or print name) AUTHORIZED REQUESTOR (Type or print) APPROVAL AUTHORITY (Please type or print name)

FY

TYPE

This project complies with Title 10, USC Section 2461, for maintenance, repair and construction contracts for real property using Operation and Maintenance funds.

COMPLETION INSTRUCTION FOR DA Form 4283 - FACILITIES ENGINEERING WORK REQUEST (Part "A" completed by requestor per instructions below) (Part "B" completed by the DPW in accordance with local procedures)

PART "A"

CUSTOMER ID: One to three alpha numeric characters per local DPW policy.

A code used to identify the user, occupant, owner of a facility, or the organizational activity submitting a work request.

DOCUMENT SERIAL NO: Must be five alpha numeric characters. Based on local procedures, this number may be generated and entered by the requestor or computer generated and assigned by DPW. It is a number which indicates a place in a series and when used in conjunction with installation number, customer identification, document type, and fiscal year, it uniquely identifies one document of a particular type.

FISCAL YEAR: The last digit of the fiscal year; i.e., '3' for Fiscal Year 2003.

TYPE: Leave blank; DPW Work Reception will complete DATE: The date Work Request was completed (Format - 15 JUL 03).

REMARKS: At a minimum, include email address of the Primary POC and an Alternate POC for requested work.

POC PHONE NUMBER: Phone number for POC of this particular work request consisting of up to 12 alpha numeric characters.

WORK DESCRIPTION: Description of work to include impact and justification.

AUTHORIZED REQUESTOR: The name of the individual who is authorized to request work.

DA FORM 4283, NOV 2018

SIGNATURE: Signature of Authorized Requestor.

SHORT JOB DESCRIPTION: Up to 30 alpha numeric characters that provide a description with a concise summary statement of the work to be performed.

INSTALLATION ABBREVIATION: Up to eight alpha numeric characters for the locally assigned abbreviation of the installation's officially designated name; e.g., Fort Benjamin Harrison abbreviated as Fort Ben.

FACILITY NUMBER: A code of five alpha numeric characters which represent the unique serial number assigned to a real property facility within an installation for identification through its life cycle, e.g. P0001.

INSTALLATION NAME: The official name of an Army real estate holding and the principal function as defined in the real property inventory, e.g., Fort Lee.

CUSTOMER NAME: The name or description of the user, occupant, owner of a facility, or the organizational activity authorized to submit a request for work consisting of up to 15 alpha numeric characters.

POC NAME: Name of the person responsible for specific work information about requested work consisting of up to 15 alpha numeric characters (Format - Last Name, First Name)

APD LC V1.00ES

1.00 DA Form 4283, NOV 2018 Facilities Engineering Work Request

APD