ORIGINATOR SHOULD COMPLETE ITEMS 1- 20. SUBMIT TO PI OR SECTION LEAD FOR CONCURRENCE (ITEM 21). SUBMIT TO SET PROJECT/SET EXP. MANAGER FOR CONCURRENCE (ITEM 22). MISC. SET SECTION LEAD AND SET QA WILL REVIEW AND APPROVE/DISAPPROVE. / 2. LWS/SET Contract #
COMPLETED, SIGNED FORM WILL BE RETURNED TO ORIGINATOR. COPY SHOULD BE INSERTED IN ACCEPTANCE DATA PACKAGE/LOGBOOK.
Deviation: authorization, granted prior to the manufacture of an item, to depart from a particular performance o r design requirement of a specification, drawing or other document, for a specific number of units or a specific period of time. Waiver: authorization to accept an item which, during manufacture or after having been submitted for inspection, is found to depart from specified requirements, but nevertheless is considered suitable for use “as is” or after repair by an approved method. (Per MIL-STD-481B) / 3. SET DeV/WAIVER Number
DW- (INSERT UNIQUE NAME + NUMBER (I.E., eXPER. nAME – 001, -002, -003, ETC.)
4. ORIGINATOR INFORMATION: / c. ADDRESS (Employer, Street no., City, State, Zip Code, Phone Number) / 5. (check one)
a. TYPED NAME (First, Middle Initial, Last) / DEVIATION / WAIVER
6. (GSFC USE) / MINOR
b. TYPED TITLE: / MAJOR / CRITICAL
7. EXPERIMENTER INFORMATION: / 8. BASELINE AFFECTED (GSFC USE) / 9. OTHER SYSTEM AFFECTED? (GSFC USE)
a. SYSTEM/EXPERIMENT NAME / b. CAGE CODE / c. ADDRESS / (if different from 4c) / FUNCTIONAL / (Next Level Assembly, Mechanical, Thermal, etc.)
Yes No
DOCUMENTATION
10. DESCRIPTION OF DEVIATION/WAIVER
11. NAME OF LOWEST PART/ASSEMBLY AFFECTED: Payload __ Instrument __ Subsystem __ PWA/Card __ Component __ (complete blocks 12)
12. AFFECTED ITEM (Component level only):
a. USE: QTY AND EFFECTED LOCATIONS (REF DES) / b. PROCURED PART NUMBER / c. GENERIC PART NUMBER / d. DESCRIPTION
13. EFFECTIVITY [AFFECTED ASSEMBLY NAME AND SERIAL NUMBER(s)] / 14. RECURRING DEVIATION/WAIVER FROM PREVIOUS BUILD?
YES / NO
15. EFFECT ON COST/PRICE / 16. EFFECT ON DELIVERY SCHEDULE
- EFFECT ON INTEGRATED LOGISTICS SUPPORT, INTERFACE OR SOFTWARE (If none, enter “No effect”.)
18. DEVIATION/WAIVER REQUIRED: (Explain why deviation or waiver is needed.)
19. CORRECTIVE ACTION TAKEN:
20. ORIGINATOR INFORMATION:
a. TYPED NAME (First, Middle Initial, Last) / b. TITLE / c. SIGNATURE
21. PI/LEAD APPROVAL/DISAPPROVAL
/ a. RECOMMEND: / __ APPROVAL / __ DISAPPROVAL
21b. TYPED NAME
TYPED TITLE / c. SIGNATURE / d. DATE SIGNED
22. SET PROJECT APPROVAL/DISAPPROVAL / a. RECOMMEND: __APPROVAL __ DISAPPROVAL / APPROVAL / DISAPPROVAL
22b. TYPED NAME (First , Middle Initial, Last)
TYPED TITLE / c. SIGNATURE / d. DATE SIGNED
23. SET PROJECT APPROVAL/DISAPPROVAL / a. RECOMMEND: __ APPROVAL __ DISAPPROVAL
22b. TYPED NAME (First , Middle Initial, Last)
TYPED TITLE / c. SIGNATURE / d. DATE SIGNED
23. SET QA APPROVAL/DISAPPROVAL / a. RECOMMEND: __ APPROVAL __ DISAPPROVAL
23b. TYPED NAME (First , Middle Initial, Last)
TYPED TITLE / c. SIGNATURE / d. DATE SIGNED
SET DEV/WAVIER FORM - LWSSET-QA-0003 (MAY2004) (Computer Generated)