Block 10. Describe the damage to the weapon, the level of repairs required, and any damage to other
materiel. Continue this item on the back of the form or on a separate sheet, if necessary.
Attach any appropriate photographs, sketches, and measurements.
Block 11. Self-explanatory.
Block 12. Enter the quantity of affected ammunition on hand. Also, enter any local suspension data.
Block 13. Self-explanatory.
Block 14. In Block 14a, enter the abbreviated nomenclature, the NSN, and the serial number of the
weapon or launcher in which the malfunctioning item was fired. Complete Blocks 14b
through 14m as appropriate. When appropriate, provide the following information on the
back of the form or on a continuation sheet:
The name of the manufacturer (plant or arsenal).
The number of propellant increments fired (for mortar rounds).
The condition of the weapon or launcher prior to the malfunction. Include (as applicable)
the date of the last overhaul, the overhauling installation, the timing and headspace
dimensions of the weapon (by actual gauge check), the date of the last cleaning, and the
date of the last boresight.
For 37mm or larger weapons, enter the total number of rounds fired through the tube
before the malfunction. Read and report the pullover gauge reading of the damaged gun
tube according to the guidance contained in TM 9-4933-200-35. If the tube has been
destroyed, or if the gauge is not available, extract the most recent pullover gauge reading
from the log book, and list the total number of rounds fired subsequent to that reading.
Block 15. Briefly describe the general conditions at the firing site and along the flight path of the item
(marsh, jungle, woods, dry grassy plain, or muddy hillside). Describe any natural or artificial
barriers that may have obstructed the line of fire (overhanging trees or heavy camouflage).
Enter the distance for which witnesses to the malfunction had an unobstructed view of the
Block 16. Enter the estimated visibility limit due to atmospheric conditions (haze, smoke, rain, or fog).
Briefly describe the nature and quantity of any precipitation either at the time of, or shortly
before the malfunction (rain, sleet, or snow). Enter the temperature and the relative humidity.
Block 17. Self-explanatory.
Block 18. Mark the appropriate blocks. If the package was inadequate or damaged, describe the
problem on the back of the form or on a separate continuation sheet.
Block 19. Provide the following information on the back of the form or on a separate continuation sheet:
Describe the events immediately before the malfunction and the actions taken following