REWORK, WAIVER, DEVIATION, REINSPECTION, FOREIGN MATERIAL, EXTENSION 

TEMPLATE

USE COMPANY LETTERHEAD FOR REQUEST DATE: _____________

Subject: (state type of request) request for (include the name of the product and lot number)

(If requesting a waiver and a rework, submit requests separately)

01 Type of Request: Waiver ☐ Notification ☐ Re-inspection ☐ Rework ☐

02 Nature of Request: ________________________________________________________________

03 Approval Required from DLA: Yes ☐ No ☐

04 Contractor Name/Address: __________________________________________________________

05 Contract Number: _________________________________________________________________

06 Product Name: ___________________________________________________________________

07 National Stock Number: ____________________________________________________________

08 Batch Number (s) (If Applicable): ____________________________________________________

09 Lot Number (s): ___________________________________________________________________

10 Sublot (s) (If Applicable): ___________________________________________________________

11 Process Category (ex. Work-in-progress/End Item): ______________________________________

12.a Quantities: Pouches _____ Pouches/Case _____ Cases _____ Cases/Pallet _____ Pallets _____

12.b Pouch integrity waivers/reworks: Manufacturing lines & equipment: Fill & seal machine(s) _____ Fill

& seal line(s) _____ 

12.c Other waivers/reworks: (Provide specific details regarding the manufacturing lines when the issue is 

being attributed to a particular line, batch, time, etc.) ______________________________________

13 PCR/CID/QAP Number (Spec): ______________________________________________________

14 Sample Size; Defect; Accept/Reject: ___________________________________________________

15 Defect Classification: Critical ☐ Major ☐ Minor ☐ NA ☐

16 Inspection Failure (Summary of non-conformances): ______________________________________

17 Failure Identified: Processing ☐ Packaging ☐ End Item ☐

18 Inspector: In-plant ☐ USDA ☐

19 Date of Incident: ___________________________________________________________________

20.a. Attachments (Provide in-house and USDA worksheets): ___________________________________

20.b. Attachments (Provide in process worksheets): ___________________________________________

21 Root Cause of nonconformance or deviation (Describe using a short detailed paragraph or expand as 

necessary): Note: The citation of the number of nonconformances exceeding an end-item inspections 

acceptance number is not the identification of the root cause(s) of a nonconformance. ____________

_________________________________________________________________________________

22 Corrective Action (Describe using a short detailed paragraph or expand as necessary): ___________

_________________________________________________________________________________

23 Preventive Action (Describe using a short detailed paragraph or expand as necessary): Note: (Within 

the 30 day time limit to submit a rework, identify in your request if preventive actions were deemed 

necessary, and if so what preventive actions have been implemented) _________________________

_________________________________________________________________________________

24 Occurrence (Has this occurred before/when): ____________________________________________

25 Was this lot previously reworked? If so, was it a full or partial rework? _______________________

26 Estimated Cost: ____________________________________________________________________

27 Effect on Delivery: _________________________________________________________________

28 Justification for request: _____________________________________________________________

Thank you,

Point of Contact Info with phone number and email address