COMUSFLTFORCOMINST 4790.

3 REV B CH-4

DEPARTURE FROM SPECIFICATION REQUEST

QA FORM 12
1. DEPARTURE NO. 2. SHIP 3. JCN 4. CWP/REC SER. NO. 5. DATE

6. ORIGINATOR: NAME 7. DEPARTURE TYPE MAJOR MINOR SUBSAFE SOC FBW SFCC

8. ADDITIONAL CLASSIFICATION (SHIPYARD AND SOC USE ONLY) WAIVER DEVIATION SSDR TVD FBWDR
ISIC CONCURRENCE (REQUIRED FOR CONDITIONAL DFS) YES NO
9. SYSTEM/COMPONENT/LOCATION & SHORT DESCRIPTION

10. NAVSEA DRAWING/PLAN NUMBER/PIECE NUMBER

11. REFERENCES

12. APPLICABLE SPECIFICATIONS

13. SITUATION/DEGREE OF NON-COMPLIANCE

14. COMMENTS/RECOMMENDATION (TEST CONDUCTED, AFFECTED SYSTEMS)

15. DATE ANSWER REQUESTED BY: 16. SUBMITTING ACTIVITY: TYPED OR PRINT NAME/SIGNATURE (RO/DH)

17. NEW JCN NUMBER FOR CONDITIONAL DEPARTURES:

18. DFS APPROVAL COMMENTS

ISIC APPROVED DISAPPROVED CONCUR, FORWARDED TO TYCOM LOCAL TECH AUTHORITY FOR ACTION

NAME SIGNATURE DATE

TYCOM CONCUR APPROVED DISAPPROVED FORWARDED TO NAVSEA/NAVAIR/LOCAL TECH AUTHORITY FOR ACTION

NAME SIGNATURE DATE

LOCAL TECHNICAL AUTHORITY APPROVED DISAPPROVED FORWARDED TO NAVSEA/NAVAIR FOR ACTION

NAME SIGNATURE DATE

NAVSEA/NAVAIR APPROVED DISAPPROVED TEMPORARY PERMANENT PRECEDENT

NAME SIGNATURE DATE

19. COPY TO: