Contract Data Requirements List A004- 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 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

0002

C. CATEGORY:

A

D. SYSTEM/ITEM

E. CONTRACT/PR NO.

X

F. CONTRACTOR

High Press/Temp Microwave Digestion
1. DATA ITEM NO.

A004

2. TITLE OF DATA ITEM

3. SUBTITLE

ACCIDENT/INCIDENT REPORT

N/A

4. AUTHORITY (Data Acquisition Document No.)

5. CONTRACT REFERENCE

DI-SAFT-81563 NOT 2

7. DD 250 REQ

NO

9. DIST STATEMENT

REQUIRED

8. APP CODE

A

N/A

17. PRICE GROUP

10. FREQUENCY

12. DATE OF FIRST SUBMISSION

ASREQ

WR-ALC/SE (Safety Office)
14.

DISTRIBUTION

ASREQ

11. AS OF DATE

SEE BLK 16

18. ESTIMATED

TOTAL PRICE

6. REQUIRING OFFICE

PD Para 4.13

b. COPIES

13. DATE OF SUBSEQUENT

SUBMISSION

a. ADDRESSEE

SEE BLK 16

16. REMARKS

See blk 16

Final

Draft

Reg

Repro

Block 11 & 13:
The Contractor shall notify the Robins AFB Safety Office telephonically at (478) 327-4862 during duty hours and (478) 926-3567 after hours, within four (4) hour after initial notification of all mishaps or incidents for damage to DoD property (material plus labor) entrusted by this contract and employee injuries as a result of the contract operation. A follow-up (electronically) of this mishap/incident notification shall be sent within three calendar days to the Government Representative, the Procurement Contracting Officer (PCO), Contract Surveillance Management Office (CSMO) Representative (with a copy to program manager), who will forward it to the Safety Office. The information that is not available at the time of the initial notification shall be provided within 20 calendar days after the mishap. Mishap notification shall contain, as a minimum, the following