NASA Safety Reporting System

PLACE

STAMP

H E R E

National Aeronautics and Space Administration

NSRS

PO BOX 5826

BETHESDA, MD 20824-9913

NASA SAFETY REPORTING SYSTEM

P.O. BOX 5826

BETHESDA, MD 20824-9913

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OMB No. 2700-0063

The NASA Safety Reporting System (NSRS) is an anonymous, voluntary, and responsive reporting channel to notify NASA’s upper management of your concerns about hazards. Any NASA employee or contractor employee working in support of NASA may use the NSRS to report safety concerns.

PAPERWORK REDUCTION ACT STATEMENT

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 2700-0063; it expires on xx/xx/xxxx. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate to hq-dl-nsrscontact@nasa.gov.

PLEASE NOTE: The NSRS is designed to supplement your local hazard reporting channels. You should first report any hazard or safety concern using your established safety reporting procedures. Use the NSRS if

–You have reported a hazard locally and have seen no action taken,

–You are not satisfied with the response to a reported hazard, or

–You fear reprisal if you were to report the hazard through local reporting channels.

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Please do not include classified information in your report. Fraud, waste, and abuse should be reported directly to the

NASA Inspector General by dialing the Inspector General HOTLINE at 1-800-424-9183. The NSRS contractor will forward any report inferring criminal activity to the NASA Inspector General.

DESCRIBE YOUR CONCERN

Please describe the hazard in detail. Include as much information as you can to help clarify your concern. Be sure to include:

• The scope of the hazard (does the hazard affect NASA assets, the NASA workforce, and/or the general public?);

• Manufacturing sources and/or part numbers (if hardware is involved);

• The physical location of the hazard;

• Whether or not you have reported the hazard elsewhere;

• Whether the hazard relates to a single event or a recurring process;

• What you believe caused the hazard;

• What you think can be done to correct the hazard and prevent a recurrence; and

• What you believe the consequences may be if the hazard remains unresolved.

(Please use the reverse side to describe your concerns.)

IDENTIFICATION SECTION: Please provide your name, address, and telephone number. The NSRS contractor will contact you ONLY if the information you provided needs clarification. If and when no further clarification is needed, this identification section will be separated from the report and mailed back to you to protect your anonymity.

YOUR IDENTITY WILL NOT BE SHARED WITH NASA AT ANY POINT. NO RECORD OF YOUR IDENTITY WILL BE KEPT.

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When you have completed this form, please fold, seal, affix necessary postage, and drop it in the mail. Thank you!