Block 28
Enter the number of missiles fired from the same lot on the day the malfunction occurred. Give the number of
rounds of that lot remaining on hand.
Block 29
Enter the estimated or actual distance from the launcher, in yards or meters, where the malfunction occurred.
Block 30
Show whether or not the involved lot was temporarily suspended from further issue and use.
Block 31
Check applicable blocks, showing whether fragments or other components of interest are available. Also, indicate
whether technical assistance is needed from the commodity command.
Block 32
Give other pertinent information for personnel evaluating the report. Include photographs or sketches of
important features as appropriate. If the malfunction was due to personnel error, state this. If any unusual
observations were made during preparation for firing, include a history statement.
Block 33
Enter the names and telephone numbers of witnesses (for example, Redeye gunner) or other persons who can
provide additional firsthand information.
Block 34
In Block 34a, enter the typed or printed name of the person submitting the report. In Block 34b, enter the rank of
the person listed in Block 34a. In Block 34c, enter the signature of the person submitting the report. In Block
34d, enter the date of the report.
DELAYS IN REPORTING
A preliminary report will not be delayed pending a missing data element. A detailed report bearing the same
report number as the preliminary report, along with pictorial evidence, when available, will be submitted within
10 days of the reported malfunction. This will adequately address missing data elements in the preliminary
report, and will provide additional pertinent facts. See AR 75-1 for further guidance on the timely submission of
ammunition malfunction reports.
Although it may not be possible to fulfill all of the requirements of AR 75-1 during combat operations, reports
and investigations must be as complete as possible within combat operation limits.
2-11
MM0167
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