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Use to provide initial notification (report) of a major ammunition malfunction. Reference: FM 9-6.

LINE 1 -- DATE AND TIME______________________________(DTG)

LINE 2 -- UNIT________________________________________(Unit Making Report)

LINE 3 -- ORIGINATING UNIT___________________________(Identifier for the Unit Making the Report)

LINE 4 -- DATE-TIME __________________________________(DTG at Which the Incident Occurred)

LINE 5 -- LOCATION STATUS___________________________(Status of the Location at Which the Incident Occurred)

LINE 6 -- INSTALLATION TYPE__________________________(Type of Installation or Location at Which Incident Occurred)

LINE 7 -- LOCATION DESIGNATOR______________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator of the Incident)

LINE 8 -- COUNTRY____________________________________(Country or Geographical-Political Pact of the Organization Involved in the Incident)

LINE 9 -- UTM_________________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator)

**Repeat line 9 as often as necessary to enter the UTM grid reference points.

LINE 10 -- MALFUNCTION______________________________(Enter Details and Cause of Malfunction (See NOTE 1))

LINE 11 -- DAMAGES/CASUALTIES______________________(Casualty and Damage Information)

LINE 12 -- STOCK NUMBER/CODE_______________________(National Stock Number, NATO Stock Number or National Short Code)

LINE 13 -- BATCH_____________________________________(Batch Number of the Ammunition)

LINE 14 -- LOT________________________________________(Lot Number of the Ammunition)

LINE 15 -- WEAPON____________________________________(Identifier of the Generic Type of Weapon Being

LINE 16 -- MODEL_____________________________________(Exact Weapon Model)

LINE 17 -- NUMBER____________________________________(Number of Weapons Involved)

**Repeat lines 15 through 17 for each type of weapon. Assign sequential line numbers to succeeding iterations; for example, first iteration 15 through 17; second iteration 15a through 17a; third iteration 15b through 17b; and so on.

LINE 18 -- WEATHER___________________________________(Weather Conditions at Time of Malfunction)

LINE 19 -- RANK______________________________________(Rank or Position of POC)

LINE 20 -- SURNAME__________________________________(Surname of POC)

LINE 21 -- UNIT_______________________________________(Unit POC)

LINE 22 -- TELEPHONE_________________________________(Telephone Number of POC)

LINE 23 -- ACTION TAKEN______________________________(Enter Information on Action Taken)

LINE 24 -- NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report)

LINE 25 -- AUTHENTICATION___________________________(Report Authentication)