MOD Format 755(SM2)
(Revised Jul 15)
OFFICIAL*
Service Modification Safety and Support Questionnaire
This Safety and Support Questionnaire is to be compiled using the guidance given in the RA5308.
1. Authority / PT:
2. Aircraft Type / Mark / Main Equipment:
3. Category: Safety/Operational/Engineering*
4. SM Title:
5. Is there an effect on:
Statement
a. Airworthiness and Flight Safety:
(1) Safety Case
(2) Statement of Operational Intent and Usage
(3) Operating Data Manual
(4) Release To Service
(5) Certificates of Design
(6) Structural Integrity
(7) Structural Classification
(8) Material Specification
(9) Heat Treatment
(10) Environmental Control System
(11) Aircrew Safety and Operating Procedures
(12) Aircrew Health
(13) Human Machine Interface
(14) Performance and Reliability
(15) Compatibility
(16) Interchange ability
(17) Weight and Moment
(18) Handling, Performance and Operations
(19) Hazardous Materiel.
Others (state)
* Select/delete as applicable
OFFICIAL*
(SM2) 1-4
MOD Format 755(SM2)
(Revised Jul 15)
OFFICIAL*
5. Is there an effect on:
Qualification
b. Electrical Systems and Electro–Magnetic
Compatibility (EMC)
c. Magnetic Signature
d. Acoustic and Infrared Signatures
e. Vibration Signature
f. Fire Hazard
g. Armament System
(1) Environment
(2) Structural Loading and Support
(3) Carriers
(4) Release Units
(5) Dimensions
(6) Performance
(7) Fuzing and Release Signals
(8) Fuzing and Adaptors
(9) Electrical
(10) Maintenance
Others (state)
* Select/delete as applicable
OFFICIAL*
(SM2) 2-4
MOD Format 755(SM2)
(Revised Jul 15)
OFFICIAL*
5. Is there an effect on:
Qualification
h. Integrated Logistic Support
(1) Support Policy Statement
(2) Reliability and Maintainability
(3) Spares
(4) Schedule
(5) Storage
(6) Training
(7) Support Equipment
(8) Packaging
(9) Codification
(10) Identification of Trials Equipment
(11) Manufacturing Authority
(12) Loan Items
(13) Supply of Parts and Materials
(14) Equipment Life
(15) In-Service Capabilities and Resources
(16) Repair and Overhaul
(17) Ongoing Support
Others (state)
i. Documentation
(1)
(2)
(3)
(4)
Specifications
Technical Publications
Trials Documentation
Explosive Ordnance Disposal (EOD)
Procedures
(5) Information Systems
Others (state)
j. Test Equipment (TE)
OFFICIAL*
(SM2) 3-4
MOD Format 755(SM2)
(Revised Jul 15)
OFFICIAL*
5. Is there an effect on:
k. Embodiment Checks
Qualification
l. Testing and Calibration
m. Tooling
n. Portability
o. Synthetic Trainers
p. Aircraft Security Accreditation
SSQ Originator
Name:
Rank / Grade:
Sqn. / Ship / Unit:
Completed in accordance with MOD Form 755(SM2) Version:
Signature:
Tel. No.:
Post:
Date:
Safety Questionnaire Endorsement
The SSQ has been reviewed, all potential risks have been identified and highlighted accordingly / the following risk(s) / concerns have been further identified,
which are to be addressed:
Competent person with the appropriate airworthiness delegation.
RTSA*/AWC*
Name:
Post:
Tel. No.:
Name:
Post:
Tel. No.:
Signature:
Rank / Grade:
Date:
* Select/delete as applicable.
OFFICIAL*
(SM2) 4-4
Signature:
Rank / Grade
Date: