Block 20
Enter the names and telephone numbers of witnesses and anyone who can provide additional first-hand
information.
Block 21
Enter the name and telephone number of the person who compiled the information for the report and the date of
the report. Ensure that the person who compiled the report signs it.
PREPARING THE DA FORM 4379-1-R
When the malfunction involves GMLR, report the incident using DA Form 4379-1-R. Prepare this form
according to the instructions that follow. Study the example given in Figure 2-3 and Figure 2-4 as you read the
explanation of each entry.
Block 1
Self-explanatory.
Block 2
Enter the unit identification symbol and the report number.
Block 3
Self-explanatory.
Block 4
Enter the battery, battalion, division, or other organization that experienced the malfunction.
Block 5
Enter the location where the malfunction occurred (for example, McGregor Range, Fort Bliss, TX).
Block 6
On Line a, enter the type of firing (for example, troop training, fire demonstration, standardization flight, or
annual service practice). On Line b, enter the method of firing (such as surface-to-surface or surface-to-air).
Block 7
Enter the missile's flight time in seconds. This is the length of time from the launch until the malfunction
occurred.
Block 8
Enter the missile type and model number (for example, TOW, BGM-71A2).
Block 9
Enter the missile's serial number, lot number, and NSN. Get this information from the missile body.
Block 10
Enter the warhead type. Also, provide the serial number and the lot number from the Department of Defense
(DD) Form 1650 (Ammunition Data Card).
Block 11
Enter the rocket motor model designation, the serial number, and the lot number from the DD Form 1650.
2-7
MM0167
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