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SAMPLE – Please use the guidelines on this form to complete the form on Page 2 AND delete this page when ready to submit
LHA 7 PROGRAM
CERTIFICATION OF SHOCK QUALIFICATION


State the name of the equipment and give a brief description of the equipment



This is to certify that the


characteristics

Equipment/Material Description


Manufacturer’s CURRENT drawing number and revision




Name the company who actually produced the current equipment

Manufacturer’s Part Number


Manufacturer Model Number Drawing No. and Revision


Purchase Order Line Item

Purchase Order Number



To be supplied under Ingalls Purchase Order , Item


Previous Manufacturer’s Part Number

Previous Manufacturer



Is identical with that

Manufacturer Model Number


Shipyard the previous equipment was provided to



previously qualified and supplied to Ingalls or

Other Shipbuilder


Previous Purchase Order Line Item

Previous Purchase Order Number



on Purchase Order No. , Item


Navy contract number for specific hull

Hull designation



For under Navy Contract No.




. It is further certified that the equipment was:




Grade A or Grade B Shock Qualified as identified below:




Check Boxes – Type “X” in the fields that apply
Shock Test




Shock Extension




Shock Analysis


Explanation of Previous qualification method



Other:
Attach a copy of the following:

-An authenticated, dated report of the shock test and post test inspections describing test

configuration, instrumentation, test setup (photo(s) or sketch(es) required), test levels achieved for the item

-A description of failures, if any, where applicable,

-A copy of the Navy approval letter for the tested item if one exists.


Provide any pertinent or nonstandard facts about the shock test and/or accompanying documentation



Comments:


Once the form is complete and this page has been deleted, submit the final document in to the SPARS VES System for the given PO. If you have any questions regarding SPARS, contact Ingalls Files & Records at engfr@hii-ingalls.com.




Name and Title of Signee

Name and Title of Person Authorized to Sign


Typing your name in this field constitutes a legal signature

Signature Date


LHA 7 PROGRAM
CERTIFICATION OF SHOCK QUALIFICATION





This is to certify that the


Equipment/Material Description


Manufacturer Model Number Drawing No. and Revision




To be supplied under Ingalls Purchase Order , Item




Is identical with that

Manufacturer Model Number




previously qualified and supplied to Ingalls or

Other Shipbuilder




on Purchase Order No. , Item




For under Navy Contract No.




. It is further certified that the equipment was:




Grade A or Grade B Shock Qualified as identified below:



Shock Test




Shock Extension




Shock Analysis




Other:
Attach a copy of the following:

-An authenticated, dated report of the shock test and post test inspections describing test

configuration, instrumentation, test setup (photo(s) or sketch(es) required), test levels achieved for the item

-A description of failures, if any, where applicable,

-A copy of the Navy approval letter for the tested item if one exists.




Comments:

Name and Title of Person Authorized to Sign


Signature Date

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