Instructions for DHA Form 435
Blocks
| Instructions
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1-3
| Main point of contact for Health Hazard Assessment request.
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4-8
| Leave blank.
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9
| Choose from drop down.
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10 a-c
| Same as blocks 1-3 or an alternate point of contact.
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11
| Request a Health Hazard Assessment for (System Name (System Acronym))
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12*
| Task to: AD-HCA-PH DCPH-A OHS
Request that the Health Hazard Assessment Division (OHS), Defense Centers for Public Health-Aberdeen coordinate with customer to discuss feasibility and timeline to conduct a Health Hazard Assessment for (System Name) as required by Army Regulation (AR) 40-10, AR 70-1, AR 770-3, and AR 602-2.
PEO:
Program/Product/Project Manager (PM office):
ACAT Level:
Acquisition Event:
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13
| Date submitted.
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14
| 21 calendar days from submission for all requests. Note: This date is to complete coordination.
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15
| Routine RFI/RFA - all acquisition events except Urgent Materiel Release (UMR).
Urgent RFI/RFA - UMR only.
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16
| Complete this block only if Urgent RFI/RFA is checked in block 15. Note: Ensure the materiel system is identified as a UMR in the HHA request memorandum.
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17
| Leave blank.
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*Critical.
The completed DHA Form 435 and signed HHA request memorandum on organizational letterhead are to be submitted to the following mailboxes:
To: dha.ncr.operations-j-3.mbx.rfi-mgr@health.mil
Cc: dha.apg.Pub-Health-A.list.hha@health.mil
The HHA request memorandum should include:
- Primary and technical points of contact, address, Program Executive Office, phone numbers, and e-mail.
- System nomenclature and description to include major components.
- Purpose of the system.
- Number of systems and number of users/operators per system.
- System life-cycle phase and Acquisition Category level.
- Purpose of HHA report and date required.
- System/prototype availability (where/when).
- Statement on availability of funds to support HHA effort (ACAT I - labor & travel; ACAT II, III, IV - travel).
- Names, phone numbers, e-mail addresses of system safety, human systems integration, test and evaluation points of contact.
