Company Registration Office,

Doc. # 08-QSP-F-001

___________________

Corrective and Preventive Action Request/

Root Cause Analysis Form
CPA #: ______ (To be assigned by MR)

Section A (To be filled by the person who raises the CPA):

Name & Designation: ________________________________________________________
CPA Type:
CPA Source:

Suggestion for Improvement

Operations

Inspection

Minor NC

Major NC

Internal Audit

Customer Complaint

External feedback*

* whether arising from complaints (online, offline, C&S Box), referral by an authority/other entity

Nonconformance/Problem Statement: __________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Signature: __________________

Date: _______________

Section B (To be filled by Person Assigned with the task of Analysis by MR):
Assigned by MR for Analysis to: __________________________Target Date: __________
Root Cause(s): ____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Proposed Corrective Action(s): ________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Proposed Preventive Action(s): ________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Signature: __________________

Date: _______________

Section C (To be filled by MR):

Corrective/Preventive Actions Considered: _______________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Assigned for Implementation to: ____________________ Target Date: _______________

Follow up (Date): _________________
In case Action is effective:

Action Taken

Effective

In-effective

CPA Close-out Date: _______________

In case Action is not taken or is in-effective: New CPA (Number): _________ Date: ______
MR Signature: __________________ Date: ______________