NASA Procedural Requirements

NPR 8715.1B Effective Date: February 01, 2021 Expiration Date: February 01, 2026

Subject: NASA Safety and Health Programs

Responsible Office: Office of Safety and Mission Assurance

Appendix D. Example Request For Relief Form

Instructions for completing the Requirement Request for Relief (RFR) Form

1. Date Prepared. Enter the submittal, preparation, or revision date of the RFR prepared in the format DD-Mon-YYYY (e.g., 01-Jan-2017). 2. RFR Number. Leave blank, OSMA will assign a headquarters tracking number. 3. Procuring Activity No. To be Entered by the procuring activity to provide an internal processing number, if required. 4. Title of Request: Enter a title to describe the request. 5.a-c. Scope and Duration of Requested Relief. Enter the designation of the system(s) and operation(s) for which the relief is requested and the duration of the request. Check whether the granting relief results in increased risk to safety or no increase in risk. 6.a-c. Requirement to be Relieved. Enter the source document No. (including revision letter and change No. if applicable), the requirement paragraph number, and the requirement text. 7. Description of Relief Request. Enter the description of the relief request. Describe the nature of the proposed departure from the requirement of the source document. Include marked drawings and other documents to describe and justify approval of the request. Provide the impact of other systems, operations, and organizations or programs, as required. 8. Need for Relief. Describe the need for relief from the requirement. Explain why it is not possible, or desirable, to comply with the requirement within the specified delivery schedule. Also, if applicable, explain why a relief request is proposed in lieu of a permanent design change. 9. Corrective Action Taken to Prevent Future Recurrence. Describe any action(s) taken to prevent a future recurrence of this request. 10. Effect on Safety Performance, Function, Reliability, Durability, Integrated Logistics Support, Interface, or Software. Describe the changes in performance allocations and in the function and physical interfaces defined in the system specification. Describe the

effects of the proposed change on employment, deployment, logistics, and personnel and training requirements that have been specified in the approved system, including any change or effects on the operability of the system. In particular, there is to be an entry detailing any effect on interoperability. 11.a-b. Recurrence. If the same relief has been requested previously, check "Yes" or check "No" otherwise. If block 11.a. is "Yes", provide justification for the recurrence of this relief and explain why previous corrective actions did not prevent it from recurring. 12.a-d. Originating Activity. Enter the name, organization, telephone number, and email of the technical point of contact for the RFR. 13.a-b. Submitting Authority. Enter the Submitting Authority, name, title, and signature of the individual authorized to request the RFR. Signature indicates the requester accepts the risk associated with this RFR. 14.a-b. Recommendations. Enter the name, title, signature, date signed, and recommended disposition for each reviewer. If a reviewer recommends disapproval, rationale should be provided in 14.c. 15.a. Disposition. Check the appropriate box to indicate the finale disposition of the RFR. Approved - RFR is approved as submitted; Disapproved - RFR is disapproved; 15.b. Disapproval Rationale. provide the rationale behind the disapproval recommendation. 15.c-e. Disposition. Enter the Name, Title, Signature, and Date signed. This block is to be completed by the Approving Authority. Signature indicates the request was reviewed and the request for relief either approved or disapproved.

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