ACCIDENT INCIDENT REPORT

CONTRACT DATA REQUIREMENTS LIST

Form Approved

OMB No. 0704-0188

(1 Data Item)

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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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 address. 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:

A-E

D. SYSTEM/ITEM

E. CONTRACT/PR NO.

C5 TRUNNION BEARING

1. DATA ITEM NO.

A005

8. APP CODE

N/A

F. CONTRACTOR

3. SUBTITLE

Accident Incident Report

Mishap Notification/Investigation

NSP

6. REQUIRING OFFICE

18. ESTIMATED

TOTAL PRICE

5. CONTRACT REFERENCE

PWS Paragraph 5.5.2

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

B

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

SEE BLK 16

SEE BLK 16

ABW/SE

14.

DISTRIBUTION

SEE BLK 16

13. DATE OF SUBSEQUENT

SUBMISSION

b. COPIES

a. ADDRESSEE

Final

Draft

SEE BLK 16

16. REMARKS

Exhibit
A
B
C
D
E

17. PRICE GROUP

2. TITLE OF DATA ITEM

DI-SAFT-81563

N/A

X

FD2060-27-00013

4. AUTHORITY (Data Acquisition Document No.)

7. DD 250 REQ

Reg

Repro

SEE BLK 16

Data Item No Performance Period
A005
Base Year Period
B005
Ordering Period 1
C005
Ordering Period 2
D005
Ordering Period 3
E005
Ordering Period 4

NOTE: Changes to office symbols and/or e-mail addresses, when necessary, shall be made by letter through the Government CO/ACO without further revision to this CDRL.
BLK 10: IAW AFI 91-204, if damage occurs
BLK 11: Once assets have been received after contract award BLK 12: Within 24 hours after accident/incident occurs
BLK 13: As needed, IAW AFI 91-207
BLK 14:Submit a digital copy in Microsoft® Office® or an Adobe® Portable Document Format (PDF) format to the following email Addresses: Safety Office: [email protected]