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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)

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