NASA Procedures and Guidelines
This Document is Obsolete and Is No Longer Used. Check the NODIS Library to access the current version: http://nodis3.gsfc.nasa.gov
NPR 8715.7A Eff. Date: February 24, 2014 Cancellation Date:	Expendable Launch Vehicle (ELV) Payload Safety Program
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Appendix D. Sample Certificate of ELV Payload Safety Compliance

INSTRUCTIONS FOR COMPLETION OF
CERTIFICATE OF ELV PAYLOAD SAFETY
COMPLIANCE FORM

Block A: Payload Mission: Insert the name of the payload and/or mission here.

Block B: Launch Vehicle: Identify the launch vehicle that will be carrying the payload.

Block C: Certification Statement.

Block D: List of Approved post-tailoring Equivalent Level of Safety (ELS) and Safety Waivers: List any approved post-tailoring ELS and Safety Waivers for which the ELV Payload Safety ELS/Waiver Form has been completed.

Block E: Payload Project Manager Signature and Date.

Block F: NASA SMA Technical Authority responsible for the payload Signature and Date.

Block G: PSWG Chairperson Concurrence Signature: The PSWG Chairperson signs and dates concurrence. This concurrence is based on the PSWG's review of safety submittals per NPR 8715.7, and the project's approved tailored version of NASA-STD 8719.24 Annex and represents, to the best of their knowledge, that the safety requirements are or are planned to be met. This concurrence signature represents the PSWG members and may be contingent upon certain conditions, actions, or constraints. These conditions, actions, or constraints shall be listed in Block G. Additionally, all safety-related actions shall be tracked on the mission's Safety Verification Tracking Log.

Block H. List all conditions, actions, or constraints not annotated on the Safety Verifications Tracking Log (attached) if necessary.

Block I. The NASA ELV Payload Safety Program Manager signature signifies that Payload Project and PSWG have adhered to or are planning to adhere to the processes and requirements of NPR 8715.7, and the project's approved tailored version of NASA-STD 8719.24 Annex. This signature also represents concurrence from the ELV Payload Safety Agency Team.

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