Contract Data Requirements List A011 - 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

0003

C. CATEGORY:

A/B/C/D/E

D. SYSTEM/ITEM

E. CONTRACT/PR NO.

F. CONTRACTOR

ISO 50001 Program
1. DATA ITEM NO.

2. TITLE OF DATA ITEM

AB/C/D/E011 Accident/Incident Report

Mishap Notification

4. AUTHORITY (Data Acquisition Document No.)

5. CONTRACT REFERENCE

DI-SAFT-81563/T NOT 1

7. DD 250 REQ

NO

8. APP CODE

A

9. DIST STATEMENT

REQUIRED

A

17. PRICE GROUP

3. SUBTITLE

10. FREQUENCY

12. DATE OF FIRST SUBMISSION

See Blk 16

11. AS OF DATE

See Blk 16

18. ESTIMATED

TOTAL PRICE

6. REQUIRING OFFICE

PWS Para 4.18

WR-ALC/SE (Safety Office)
14.

DISTRIBUTION

See Blk 16

13. DATE OF SUBSEQUENT

SUBMISSION

b. COPIES

a. ADDRESSEE

16. REMARKS

Final

Draft

See Blk 16

SEE BLOCK 16

Reg

Repro

Block 10, 11, 12, and 13: (See Appendix C, Part II, Para 5) 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 (written or e-mail) of this mishap/incident notification shall be sent within three calendar days to the Government Representative, the Procurement Contracting Officer (PCO), 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. (See PWS for complete instructions)