CDRL_A019_Accident_Incident_Report.docx
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- Part 3 of 3- Complete RFP (Sections A through M) for Mortar Weapon System: W15QKN-15-R-0017
- Solicitation number
- W15QKN15R0017
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CDRL A019
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CONTRACT DATA REQUIREMENTS LIST (1 Data Item)
| Form Approved OMB No. 0704-0188 |
| | |
| Public reporting burden for this collection of information is estimated to average 440 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 this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Managements and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20403. Please DO NO RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E. |
| | |
| A. CONTRACT NO.LINE ITEM |
| B. EXHIBIT |
| C. CATEGORY: |
| | |
| TDP______ TM______ OTHER____________________ |
| | |
| D. SYSTEM/ITEM |
| E. CONTRACT/PR NO. |
| F. CONTRACTOR |
| | |
| Mortar Weapon Systems |
| | |
| 1. DATA ITEM NO. |
| 2. TITLE OF DATA ITEM |
Accident / Incident Report
| 3. SUBTITLE |
| | |
| 17. PRICE GROUP |
A019
| | |
4. AUTHORITY (Data Acquisition Document No.)
| 5. CONTRACT REFERENCE |
| 6. REQUIRING OFFICE |
| | |
| 18 ESTIMATED |
| DI-SAFT-81563 |
| C.5.1 |
| SFAE-AMO-CAS |
| | |
| TOTAL PRICE |
| 7. DD 250REQ |
| 9. DIST STATEMENT REQUIRED |
D
| 10. FREQUENCY |
| 12. DATE OF FIRST SUB. |
| 14. DISTRIBUTION |
| AS REQ |
| AS REQ |
| a. ADDRESSEE |
| b. COPIES |
| | |
8. APP CODE
| 11. AS OF DATE |
| 13. DATE OF SUBS. SUB |
| Draft |
| Final |
| | |
| AS REQ |
| AS REQ |
| Reg |
| Repro |
| | |
16. REMARKS
RDAR-MEM-M
Mortar weapons systems
BLK 12: A separate accident / incident report in contractor format is to be submitted without delay after each occurrence.
This report provides the procuring agency with immediate notification and information concerning any major accident incident (including fire) resulting in any one or more of the following: causing one or more fatalities, or two or more disabling injuries, damaging USG property exceeding $10,000, at testing program planning or production schedules, degrading the safety of the equipment under contract, such that personnel injury or property damage may be involved, identifying a potential hazard requiring corrective action.
BLK 14: Submit electronically to:
See Section J
SFAE-AMO-CAS-GMS
| 15. TOTAL ----------> |
| 0 |
| 2 |
| 0 |
| | |
G. PREPARED BY
F.CHASTEK
RDAR-EIQ-PE
| H. DATE |
| I. APPROVED BY |
F.CHASTEK
RDAR-EIQ-PE
J. DATE
20 JAN 2015
20 JAN 2015
| DD FORM 1423-1, FEB 2001 |
| PREVIOUS EDITIONS ARE OBSOLETE Page____ of____Pages |
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