CDRL PM-28 Accident Reporting.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved (1 Data Item) OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 220 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:

TDP TM OTHER

General

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

Logistic Support Services W52P1J-15-R-0195

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE 17. PRICE GROUP

PM-28 Accident Reporting

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE 18. ESTIMATED

TOTAL PRICE

PWS Para. 1.8.2 COR/PM/Safety Office

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

10. FREQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

NO After each accident

See Blk 16 b. COPIES

8. APP CODE 11. AS OF DATE 13. DATE OF SUBSEQUENT

SUBMISSION

a. ADDRESSEE DRAFT FINAL

Date of Accident See Blk 16 Reg Repro

16. REMARKS COR 1

Block 12 & 13 – Verbal and email notification not later than 3 hours after occurrence for injury to personnel or damage to GFP. Written notification with complete details within 72 hours to the Safety Officer/CDR with interim reports at 24 hours, 48 hours and as needed/available.

Contractor will use DA Form 285 AB when required IAW AR-385-10, DA PAM 385- 40 and the DA Form 285 AB Abbreviated Ground Accident Report (AGAR) [see safety.army.mil].

The Contractor shall submit notifications (verbal/written) including, but not limited to the following:

a. Time and date of accident.

b. Time and date of initial notification.

c. Description of the accident.

d. Location of the accident including functional area, section, and room number (if applicable).

e. Contributing factors.

f. Root cause of accident, if known.

ALL DAYS INDICATED ARE CALENDAR DAYS UNLESS OTHERWISE

ANNOTATED.

Safety Officer 1

PM 1

15. TOTAL 3

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

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