Figure 2-2. Sample of a completed DA Form 4379-R (back).
For all other conventional munitions, such as grenades, rockets, mines, smoke pots, pyrotechnics,
demolition items, cartridge-actuated devices, and propellant-actuated devices, enter the type, model,
NSN, DODIC, and lot number of the end item and any components (such as fuzes, rocket motors, and
bursters). Also, provide the type of filler present in chemical munitions.
For conventional or chemical-filled warheads and warhead sections that are not assembled to GMLR,
enter the type of filler present in chemical munitions; the type, model, and lot number of the fuze; and the
type, model, and lot number of the propulsion system. Also, give the type, model, and lot number of the
adaption kit or adaption kit component involved in the malfunction.
Block 4
Enter a brief description of the malfunction.
Block 5
Enter the geographic location where the malfunction occurred.
Block 6
Enter the activity and address of the person to contact to gain access to the malfunction site.
Block 7
Enter the unit that was firing at the time of the malfunction.
Block 8
Enter the date and the local time of the malfunction.
Block 9
Enter any casualties (killed, hospitalized, and other injuries) that resulted from the malfunction.
MM0167
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