B08 - Attachment 0004 - RFV Form DD1694 Example Only (dated 6_5_25).pdf

PREVIOUS EDITION IS OBSOLETEDD FORM 1694, APR 2017 Page 1 of 2 AEM LiveCycle Designer

REQUEST FOR VARIANCE

(RFV)

1. DATE

PREPARED:

(DD-MMM-YYYY)

14-FEB-2024

2. RFV NUMBER:

24CK999-V001

3. PROCURING ACTIVITY NO. (PAN):

N00104

OMB No. 0704-0188 OMB approval expires October 31, 2019

The public reporting burden for this collection of information, 0704-0188, is estimated to average 2 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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 COMPLETED FORM TO THIS ADDRESS. RETURN COMPLETED FORM TO THE ACQUIRER ISSUING CONTRACTING OFFICER

FOR THE CONTRACT/PROCURING ACTIVITY NUMBER LISTED IN BLOCK 22 OF THIS FORM.

DISTRIBUTION STATEMENT:

DISTRIBUTION STATEMENT D: Distribution authorized to Department of Defense and U.S. DoD contractors only; Controlled Technical Information (CTI); January 1, 2024. Other requests for this document shall be referred to Commanding Officer or Technical Director, NSWC Indian Head Division.

4. TITLE OF VARIANCE: JM60 Catapult battery voltage check

5. VARIANCE PRE OR POST-PRODUCTION: 6. BASELINE AFFECTED:

Pre-Production Post-Production Functional Allocated Product

7. SYSTEM

INFORMATION

7.a. MODEL/TYPE DESIGNATION:

CKU-5C/A (JM60)

7.b. SYSTEM/CONFIG. ITEM NOMENCLATURE:

F-16, F-22

7.c. END ITEM CAGE CODE:

14083

8. AFFECTED ITEM NOMENCLATURE:

Inflation Device,Water Activated FLU-11/A

9. PART NUMBER(S) OF AFFECTED ITEM(S):

855AS110, 1812-172-01

10.a. OTHER EXTERNAL SYSTEM AFFECTED?:

Yes No

10.b. IF YES, LIST OTHER SYSTEMS OR CONFIGURATION ITEMS AFFECTED:

Training System XXX

11. IDENTIFICATION

OF VARIANCE

11.a. VARIANCE CLASSIFICATION:

Critical Major Minor

11.b. DEFECT NO.

(if applicable):

N/A

11.c. DOCUMENT DEFINING DEFECT NO./CLASS (if applicable):

N/A

12. DESCRIPTION OF VARIANCE:

Add battery voltage check after NO-FIRE SENSITIVITY. See attachment.

13. NEED FOR VARIANCE:

Voltage needs to be checked after electrical test and before functional tests to ensure the No-Fire tests did not reduce the battery voltage below required volts.

14. CORRECTIVE ACTION TAKEN:

ECPXX-XXX is in the process of being approved to update the TDP.

15. EFFECT ON PERFORMANCE, FUNCTION, RELIABILITY, DURABILITY, INTEGRATED LOGISTICS SUPPORT, INTERFACE, OR SOFTWARE:

None.

16. RECURRENCE 16.a. RECURRING VARIANCE?:

Yes No

16.b. IF YES, PROVIDE RATIONALE:

Prior RFV XXXX-XXX was limited to Lot K099-12222. ECP was drafted at the same time, but not yet approved and implemented.

17. EFFECTIVITY: (Quantity Affected, Lot Numbers Affected, Serial Numbers, Dates)

Lots K999-12345 and K999-67890

18. PER UNIT COST IMPACT:

$0.00

19. TOTAL COST IMPACT:

$0.00

20. EFFECT ON SCHEDULE IF APPROVED/DISAPPROVED:

No impact to the schedule

21. CONTRACT

INFORMATION

21.a. SUPPLIER:

ABC Manufacturing, Inc.

21.b. CONTRACT NO. AND LINE ITEM:

N00104-23-C-K999 CLIN 001

22. CONTRACTING

OFFICER

22.a. NAME:

Jane Doe

22.b. TELEPHONE:

+1 (555) 555-5555

22.c. E-MAIL:

jane.doe@navy.mil

RFV Form DD1694 Example Only dated 06/05/2025

EXAMPLE

melina.andino-rivera Line melina.andino-rivera Line melina.andino-rivera Line melina.andino-rivera Line tammy.l.riemer Callout Verity distribution statement with the contract.

tammy.l.riemer Callout Brief description of intent/purpose to include identifying info such as DODIC/model/type tammy.l.riemer Callout Describe the corrective actions taken or will be taken to prevent a future recurrence of this variance.

tammy.l.riemer Text Box Block 16a is only marked if the same request has been approved in the past. Block 16b will include the approved RFV number of the previous request. Approved RFVs should rarely be submitted on a recurring basis.

melina.andino-rivera Line melina.andino-rivera Line tammy.l.riemer Text Box Per Section B of the contract ("See attached" if cont. page if needed). Nomenclature name should match affected item name.

tammy.l.riemer Text Box Add affected, quantity, Lot Numbers and serial numbers tammy.l.riemer Line tammy.l.riemer Callout Critical tammy.l.riemer Callout Verity date with the contract.

tammy.l.riemer Callout End item cage code tammy.l.riemer Callout If needed, Enter the supplier defect number, which corresponds with the variance listing of defect characteristic(s) from which an authorized variance can be released, when appropriate. Otherwise, disregard and enter N/A.

tammy.l.riemer

If needed, enter the appropriate title or reference number of the supplier document that details/lists the defect numbers, or identifies the variance classification based on the defect number definition(s), when appropriate. Otherwise, disregard and enter N/A.

tammy.l.riemer Callout Describe the nature of the proposed include marked drawings and/or other relevant documents.

tammy.l.riemer Callout Block 18 & 19 Enter the per unit cost/ impact of the variance, and if accepted post-production, a reduction in cost (enclosed in parentheses) should be presented. If needed tammy.l.riemer Callout Describe any changes to the schedule dependent on the final disposition for the variance.

If the per-unit cost in Box 18 and the total cost in Box 19 are both $0.00, then Box 20 should indicate that there will be no cost impact.

oluwafemi.richards Rectangle

PREVIOUS EDITION IS OBSOLETEDD FORM 1694, APR 2017 Page 2 of 2 AEM LiveCycle Designer

23. ORIGINATING

ACTIVITY

23.a. NAME: John Smith

23.c. TELEPHONE: +1 (123) 456-7890

23.d. CAGE CODE:XXXXX 23.e. E-MAIL: john_smith@abcmanufacturing.com

23.b. ADDRESS: (Street, City, State, Zip Code)

XXX Alphabet Street Somewhere, DC 22222

24.a. SUBMITTING AUTHORITY:

ABC Manufacturing

24.b. NAME AND TITLE:

John Smith, Manufacturing Manager

24.c. SIGNATURE:

BELOW TO BE COMPLETED BY THE APPROVING ACTIVITY

25.a. RECOMMENDATION: Approval Approval with Modification Disapproval

25.b. MODIFICATION DESCRIPTION:

25.c. NAME AND TITLE: 25.d. SIGNATURE: 25.e. DATE: (DD-MMM-YYYY)

26.a. DISPOSITION: (Configuration Approval Authority) Approved Approved with Modification Disapproved

26.b. MODIFICATION DESCRIPTION:

26.c. NAME AND TITLE: 26.d. SIGNATURE: 26.e. DATE: (DD-MMM-YYYY)

27. LIST OF ATTACHMENTS

List Of Attachments (1)

Block 12 - Additional Information.pdf

EXAMPLE

tammy.l.riemer

Signature of the authorized individual that will be submitting the RFV.