Fillable Form 5: FACILITIES ENGINEERING WORK REQUEST (US Army)

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Form 5: FACILITIES ENGINEERING WORK REQUEST (US Army)

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  • 15 check-boxes
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DA FORM 4283, AUG 1978, IS OBSOLETE.
FACILITIES ENGINEERING WORK REQUEST
For use of this form, see DA Pam 420-6; the proponent agency is OACSIM.
PART A
(See requestor
instructions)
CUSTOMER
ID
DOCUMENT
SERIAL
NUMBER
SHORT JOB DESCRIPTION
DATE
DA MON YR
INSTALLATION
ABBREVIATION
OF FACILITIES
BUILDING/FACILITY NUMBERS
1
2
3
4
5
6
7 8
9
10
1
2
3
REMARKS
INSTALLATION NAME CUSTOMER NAME POC NAME POC PHONE NUMBER
PART B
(Approving Official Only)
APD LC v2.00ES
DA FORM 4283, SEP 2003
Page 1 of 2
APPROVAL ACTION CODE:
WORK REQUEST PRIORITY:
PROGRAM INDICATOR CODE:
DATE
DA MON YR
SPECIAL INTEREST CODE:
ESTIMATED WORK START DATE:
ESTIMATED WORK COMPLETION
DATE:
DATE
DA MON YR
DATE
DA MON YR
APPROVAL ACTION
ENVIRONMENTAL IMPACT
YES NO
ENVIRONMENTAL
CONSIDERATION
EIS / EIA
INITIATED
EIS / EIA
COMPLETED
APPROVED
DISAPPROVED
IN-HOUSE
SELF-HELP
CONTRACT
TROOP
WORK TO BE PERFORMED SOURCE OF FUNDS
ACCOUNT PROCESSING CODE
WORKCLASS APPROVAL AMOUNTS
$
$
$
$
$
$
$
$
FUNDED UNFUNDED
TOTAL
DIRECT
AUTOMATIC REIMBURSEMENT
FUNDED REIMBURSEMENT
AUTHORIZED REQUESTOR SIGNATURE
DESIGN APPROVAL SIGNATURE APPROVAL AUTHORITY SIGNATURE
WORK DESCRIPTION (Description and justification of work request)
DESIGN APPROVAL (Please type or print name)
AUTHORIZED REQUESTOR (Type or print)
APPROVAL AUTHORITY (Please type or print name)
FY
TYPE
This project complies with Title 10, USC Section 2461, for maintenance, repair and construction contracts for real property using Operation and Maintenance funds.
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COMPLETION INSTRUCTION FOR DA Form 4283 - FACILITIES ENGINEERING WORK REQUEST
(Part "A" completed by requestor per instructions below)
(Part "B" completed by the DPW in accordance with local procedures)
PART "A"
CUSTOMER ID: One to three alpha numeric characters per local DPW policy.
A code used to identify the user, occupant, owner of a facility, or the organizational activity submitting a work request.
DOCUMENT SERIAL NO: Must be five alpha numeric characters. Based on local procedures, this number may be generated and entered by the
requestor or computer generated and assigned by DPW. It is a number which indicates a place in a series and when used in conjunction with
installation number, customer identification, document type, and fiscal year, it uniquely identifies one document of a particular type.
FISCAL YEAR: The last digit of the fiscal year; i.e., '3' for Fiscal Year 2003.
TYPE: Leave blank; DPW Work Reception will complete
DATE: The date Work Request was completed (Format - 15 JUL 03).
REMARKS: At a minimum, include email address of the Primary POC and an Alternate POC for requested work.
POC PHONE NUMBER: Phone number for POC of this particular work request consisting of up to 12 alpha numeric characters.
WORK DESCRIPTION: Description of work to include impact and justification.
AUTHORIZED REQUESTOR: The name of the individual who is authorized to request work.
DA FORM 4283, SEP 2003
SIGNATURE: Signature of Authorized Requestor.
SHORT JOB DESCRIPTION: Up to 30 alpha numeric characters that provide a description with a concise summary statement of the work to be
performed.
INSTALLATION ABBREVIATION: Up to eight alpha numeric characters for the locally assigned abbreviation of the installation's officially
designated name; e.g., Fort Benjamin Harrison abbreviated as Fort Ben.
FACILITY NUMBER: A code of five alpha numeric characters which represent the unique serial number assigned to a real property facility
within an installation for identification through its life cycle, e.g. P0001.
INSTALLATION NAME: The official name of an Army real estate holding and the principal function as defined in the real property inventory,
e.g., Fort Lee.
CUSTOMER NAME: The name or description of the user, occupant, owner of a facility, or the organizational activity authorized to submit a
request for work consisting of up to 15 alpha numeric characters.
POC NAME: Name of the person responsible for specific work information about requested work consisting of up to 15 alpha numeric
characters (Format - Last Name, First Name)
APD LC v2.00ES
Page 2 of 2
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Form 5: FACILITIES ENGINEERING WORK REQUEST (US Army)

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Completed 7 April 2022

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