Standard Form 368 - Product Quality Deficiency Report
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Category I
Category II
PRODUCT QUALITY DEFICIENCY REPORT
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Info Only PQDR
Repairable Item? <choose>
1a. FROM (Original Office Mailing Address)
2a. TO (PQDR Screening Point)
1b. ORIGINATOR NAME, PHONE NUMBER & E-MAIL ADDRESS
1c. DATE SUBMITTED
2b. NAME, TELEPHONE NUMBER & E-MAIL
2c. DATE
MMO NAME, PHONE NUMBER & E-MAIL ADDRESS
ADDRESS
3. REPORT CONTROL NUMBER
4. DATE DEFICIENCY
5. DEFECTIVE ITEM NATIONAL
6. DEFECTIVE ITEM NOMENCLATURE
WAS DISCOVERED
STOCK NUMBER (NSN)
7a. MANUFACTURER OR REPAIR DEPOT / CITY / STATE
7b. MANUFACTURER’S
7c. SHIPPER / CITY /
8. DEFECTIVE ITEM
CAGE CODE
STATE
PART NUMBER
9. SERIAL, LOT, OR BATCH NUMBER
10a. CONTRACT NUMBER
10b. PURCHASE ORDER
10c. REQUISITION
10d. GBL NUMBER
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NUMBER
/ DOCUMENT
NUMBER
Serial #:
Unknown
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Lot #:
N/A
Batch #:
11. ITEM
12. DATE RECEIVED, MANUFACTERED,
13. OPERATING TIME AT
14. GOVERNMENT FURNISHED
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REPAIRED, OR OVERHAULED
FAILURE
MATERIAL
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Original Equipment
Date Received:
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Initial
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Date Repaired:
YES
NO
Hours:
New Replacement
Repaired
Date Manufactured:
Cycles:
Date Overhauled:
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Days:
Overhauled
Miles:
Rounds:
15. QUANTITY
a. RECEIVED
b. INSPECTED
c. DEFICIENT
d. IN STOCK
(1) END ITEM NSN TYPE / MODEL / SERIES
(2) END ITEM SERIAL NUMBER
16.
a. END ITEM
DEFICIENT
ITEM
(1) NHA NSN
(2) NHA NOMENCLATURE
(3) NHA PART
(4) NHA SERIAL NUMBER
b. NEXT HIGHER
WORKS
NUMBER
ASSEMBLY (NHA)
ON/WITH
17. DEFECTIVE ITEM UNIT COST
18. ESTIMATED REPAIR COST
19a. ITEM UNDER WARRANTY
19b. WARRANTY EXPIRATION DATE
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$
$
YES
NO
UNKNOWN
20. END ITEM TAM
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21a. ACTION REQUESTED (Select only one value)
REPLACEMENT
REPAIR
CREDIT
OTHER (Explain in Block 22)
21b. CURRENT DISPOSITION OF DEFECTIVE ITEM (the Exhibit)
(Select only one value)
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HOLDING EXHIBIT FOR 30 DAYS
RELEASED FOR INVESTIGATION
RETURNED TO STOCK
DISPOSED OF
REPAIRED
OTHER (Explain in Block 22)
22. DESCRIPTION OF THE DEFECT (Describe in detail what is wrong, circumstances prior to the difficulty, probable cause, any action taken, recommendations.
Attach copy of supporting documents. Continue on separate sheet if necessary.)
23. LOCATION OF DEFICIENT MATERIAL (e.g. Base, Camp, Station)
368-102
STANDARD FORM 368 (REV. 6/2007)
NSN 7540-00-133-5541
GENERAL SERVICES ADMINISTRATION
(FPMR 101 – 26.8)
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