**Standard TA Waiver Request Form (070706INTERIM with mods)**

+---------------------------+---+------------+-------------+------------+
| **Organization Requesting |   | **Date of  | **System    |            |
| Waiver:**                 |   | Request:** | Waiver #:   |            |
|                           |   |            | \_\_\       |            |
|                           |   |            | _\_\_\_\_** |            |
|                           |   |            |             |            |
|                           |   |            | **Title:**  |            |
|                           |   |            |             |            |
|                           |   |            | **Req Org   |            |
|                           |   |            | #:**        |            |
+---------------------------+---+------------+-------------+------------+
| **Initiator               |   | **Waiver   |             |            |
| Name/pho                  |   | effects:** |             |            |
| ne/e-mail/Organization:** |   |            |             |            |
|                           |   | **Duration |             |            |
| Signature:                |   | of Waiver: |             |            |
| \_\_\_\_\_\_\_\_\_\_\_\   |   | [\_\_\_\   |             |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |   | _\_\_\_\_\ |             |            |
|                           |   | _\_\_\_\_\ |             |            |
|                           |   | _\_\_]{.un |             |            |
|                           |   | derline}** |             |            |
|                           |   |            |             |            |
|                           |   | **Waiver   |             |            |
|                           |   | Risk       |             |            |
|                           |   | Scope:     |             |            |
|                           |   |     \_\    |             |            |
|                           |   | _\_\_\_\_\ |             |            |
|                           |   | _\_\_\_\_\ |             |            |
|                           |   | _\_     ** |             |            |
|                           |   |            |             |            |
|                           |   | **NASA     |             |            |
|                           |   | Personnel  |             |            |
|                           |   | Safety:    |             |            |
|                           |   | Yes No**   |             |            |
|                           |   |            |             |            |
|                           |   | **Public   |             |            |
|                           |   | Safety:    |             |            |
|                           |   | Yes No**   |             |            |
|                           |   |            |             |            |
|                           |   | **Public   |             |            |
|                           |   | Assets:    |             |            |
|                           |   | Yes No**   |             |            |
|                           |   |            |             |            |
|                           |   | *          |             |            |
|                           |   | *Federal/S |             |            |
|                           |   | tate/Local |             |            |
|                           |   | P          |             |            |
|                           |   | olicy/Law: |             |            |
|                           |   | Yes No**   |             |            |
|                           |   |            |             |            |
|                           |   | **OCE      |             |            |
|                           |   | Category:  |             |            |
|                           |   | Yes No**   |             |            |
|                           |   |            |             |            |
|                           |   | **OCHMO    |             |            |
|                           |   | Category:  |             |            |
|                           |   | Yes No**   |             |            |
+---------------------------+---+------------+-------------+------------+
| **Requirement needing     |   |            |             |            |
| Waiver:**                 |   |            |             |            |
|                           |   |            |             |            |
| **Document:**             |   |            |             |            |
|                           |   |            |             |            |
| **Paragraph:**            |   |            |             |            |
|                           |   |            |             |            |
| **System Requirement ID   |   |            |             |            |
| \#**:                     |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Additional              |   | **Risk     |             |            |
| Documentation Affected:** |   | Affected   |             |            |
|                           |   | by         |             |            |
|                           |   | Request:** |             |            |
|                           |   | ☼ None     |             |            |
|                           |   |            |             |            |
|                           |   | ☼ Ground   |             |            |
|                           |   | ☼  Flight  |             |            |
|                           |   | ☼ Software |             |            |
|                           |   | ☼ Facility |             |            |
|                           |   |            |             |            |
|                           |   | Spe        |             |            |
|                           |   | cifically: |             |            |
+---------------------------+---+------------+-------------+------------+
| **Parentage of            |   | **Lead TA  |             |            |
| Requirement:**            |   | & Role:**  |             |            |
|                           |   |            |             |            |
|                           |   | SMA        |             |            |
|                           |   | **         |             |            |
|                           |   | [L]{.under |             |            |
|                           |   | line}**ead |             |            |
|                           |   |            |             |            |
|                           |   | CE         |             |            |
|                           |   | **[M]{.    |             |            |
|                           |   | underline} |             |            |
|                           |   | **andatory |             |            |
|                           |   |            |             |            |
|                           |   | CHMO       |             |            |
|                           |   | *          |             |            |
|                           |   | *[N]{.unde |             |            |
|                           |   | rline}**/A |             |            |
|                           |   |            |             |            |
|                           |   | Other      |             |            |
|                           |   | {none}     |             |            |
+---------------------------+---+------------+-------------+------------+
| **Implementation:         |   |            |             |            |
| [P]{                      |   |            |             |            |
| .underline}**rogrammatic, |   |            |             |            |
| **[I]{.                   |   |            |             |            |
| underline}**nstitutional, |   |            |             |            |
| **[H]{.underline}**Q,     |   |            |             |            |
| **[O]{.underline}**ther   |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Text of Requirement to  |   |            |             |            |
| be Waived:**              |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Summary of Waiver       |   |            |             |            |
| Requested:**              |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Alternate Requirement   |   |            |             |            |
| to be Imposed:**          |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Reason/Justification    |   |            |             |            |
| for request:**            |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Summary of Additional   |   |            |             |            |
| Information Supporting    |   |            |             |            |
| the Waiver Request        |   |            |             |            |
| Attached :**              |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Change in Risk if       |   |            |             |            |
| Waiver is approved**:     |   |            |             |            |
| (Include stated           |   |            |             |            |
| requirement risk and risk |   |            |             |            |
| due to Waiver)            |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Summary of Risk         |   |            |             |            |
| Mitigation to be          |   |            |             |            |
| added/modified:**         |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Summary of Risk         |   |            |             |            |
| Quantification Analyses   |   |            |             |            |
| and Mitigation Plans      |   |            |             |            |
| attached:**               |   |            |             |            |
+---------------------------+---+------------+-------------+------------+
| **Required Signatures\    | * |            | **Date**    | **Concur   |
| **(per NPR 7120.5C/D      | * |            |             | /Approve** |
| Paragraph 3.1 &           | S |            |             |            |
| NPR 8715.3 paragraph      | i |            |             |            |
| 1.13)                     | g |            |             |            |
|                           | n |            |             |            |
|                           | a |            |             |            |
|                           | t |            |             |            |
|                           | u |            |             |            |
|                           | r |            |             |            |
|                           | e |            |             |            |
|                           | * |            |             |            |
|                           | * |            |             |            |
+---------------------------+---+------------+-------------+------------+
| SMA TA Risk               |   |            | / /         | **[C       |
| Review:\_\                |   |            |             | ]{.underli |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |   |            |             | ne}**oncur |
|                           |   |            |             | **[R       |
|                           |   |            |             | ]{.underli |
|                           |   |            |             | ne}**eject |
+---------------------------+---+------------+-------------+------------+
| OCE TA Engr Review:       |   |            | / /         | **[C       |
| \                         |   |            |             | ]{.underli |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |   |            |             | ne}**oncur |
|                           |   |            |             | **[R       |
|                           |   |            |             | ]{.underli |
|                           |   |            |             | ne}**eject |
+---------------------------+---+------------+-------------+------------+
| SMA TA                    |   |            | / /         | **[C       |
| Concurrence:\_\           |   |            |             | ]{.underli |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |   |            |             | ne}**oncur |
|                           |   |            |             | **[R       |
|                           |   |            |             | ]{.underli |
|                           |   |            |             | ne}**eject |
+---------------------------+---+------------+-------------+------------+
| OCE TA Concurrence:       |   |            | / /         | **[C       |
| \                         |   |            |             | ]{.underli |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |   |            |             | ne}**oncur |
|                           |   |            |             | **[R       |
|                           |   |            |             | ]{.underli |
|                           |   |            |             | ne}**eject |
+---------------------------+---+------------+-------------+------------+
| NASA Lead TA: \_\_[Chief, |   |            | / /         | **[A       |
| SMA                       |   |            |             | ]{.underli |
| ]{.underline}\_\_\_\_\_\_ |   |            |             | ne}**ccept |
|                           |   |            |             | & Grant    |
| -   For acceptance of     |   |            |             |            |
|     technical merit       |   |            |             | **[R       |
|                           |   |            |             | ]{.underli |
| -   For granting waiver   |   |            |             | ne}**eject |
+---------------------------+---+------------+-------------+------------+
| Requesting organization:  |   |            | / /         | **[A       |
|                           |   |            |             | ]{.underli |
| -   For acceptance of     |   |            |             | ne}**ccept |
|     residual risk         |   |            |             | &          |
|                           |   |            |             | [Impl]{.   |
|                           |   |            |             | underline} |
|                           |   |            |             |            |
|                           |   |            |             | **[C       |
|                           |   |            |             | ]{.underli |
|                           |   |            |             | ne}**ancel |
|                           |   |            |             |            |
|                           |   |            |             | **[        |
|                           |   |            |             | D]{.underl |
|                           |   |            |             | ine}**efer |
+---------------------------+---+------------+-------------+------------+
| **Dispositioning TA       |   |            |             |            |
| Comments:**               |   |            |             |            |
+---------------------------+---+------------+-------------+------------+

**ATTACHMENT:**