COMUSFLTFORCOMINST 4790.

3 REV B CH-2

1. PAGE 1 OF
MAINTENANCE CERTIFICATION RECORD/RE-ENTRY CONTROL
QA FORM 9
2. [ ] SUBSAFE/RE-ENTRY [ ] NUCLEAR [ ] LEVEL I [ ] SCOPE OF CERTIFICATION [ ] SFCC [ ] OTHER
3. SHIP 4. CWP/REC SERIAL NO. REV.

HULL
5. J.O./JCN 6. ASSOCIATED CWP(s)/REC(s)

7. ORIGINATOR BADGE/GRADE/RANK 8. ORGANIZATION

9. SYSTEM REPAIRED/RE-ENTERED 10. REPAIR/RE-ENTRY LOCATION

11. COMPONENT(s)

WORK DESCRIPTION INCLUDING BOUNDARIES

12. JID MAP/DWG WITH REV

13. WORK AND TESTING TO BE PERFORMED AND WORK AND TEST REFERENCE DOCUMENTS

14. APPLICABLE JOINT NO(s), OR IF NOT SUPPLIED. SPECIFIC BOUNDARIES

APPROVAL FOR CONTROLLED WORK/RE-ENTRY

15A. PRIME APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

15B. PRIME APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

15C. PRIME APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

15D. PRIME APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

VERIFICATION AND CERTIFICATION

16. SUPPORTING DOCUMENTATION

VERIFICATION OF WORK COMPLETION

17. THE PRODUCTION WORK DESCRIBED BY THIS MCR / REC HAS BEEN ACCOMPLISHED IN ACCORDANCE WITH THE SPECIFIED INSTRUCTIONS AND THE
REQUIRED DOCUMENTATION LISTED IN BLOCK 16 HAS BEEN COMPLETED, REVIEWED AND IS CORRECT.
APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

CERTIFICATION OF DOCUMENTATION OF PRODUCTION WORK

18. ALL DOCUMENTATION AND CERTIFICATION FOR PRODUCTION WORK SPECIFIED IN BLOCK 16 HAS BEEN COMPLETED. THE DOCUMENTATION HAS BEEN
REVIEWED FOR ACCURACY AND COMPLETENESS.
APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

CERTIFICATION OF TESTING RESULTS

19. THE TESTING INVOKED FOR THIS MCR HAS BEEN COMPLETED. THE TEST DOCUMENTATION SPECIFIED IN BLOCK 16 HAS BEEN REVIEWED FOR
ACCURACY AND COMPLETENESS.
APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

FINAL MCR CLOSEOUT CERTIFICATION

20. ALL CERTIFICATIONS RELATED TO THIS MCR HAVE BEEN REVIEWED FOR CORRECTNESS AND VERIFIED TO BE COMPLETE. I CERTIFY THIS QA
CERTIFICATION/RE-ENTRY IS CLOSED.
PRIME APPROVAL SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & BADGE/GRADE/RANK DATE

21. SHIP'S COMMANDING OFFICER SIGNATURE LEGIBLY PRINTED, TYPED OR STAMPED NAME & GRADE/RANK DATE