Form No.

PG ComVal (DdO)_01 Rev 01

Name of Organization: RFA No. Date Issued:

Provincial Government of Compostela Valley
(Davao de Oro)
REQUEST FOR ACTION (RFA)
Section 1: Details of Nonconformity / OFI (to be accomplished by Auditor / Initiator)
1.1 Reference (s):


1.2 Indicate type (mark with “x”)

NC (Nonconformity) OFI (Opportunity for Improvement)
Others (pls specify):
1.3 Details (mark with “x”)
Internal Quality Audit Customer Complaint / Feedback
AdHoc Audit Others (pls specify)

Issued by: Issued to (Office Head / In-Charge):

_____________________________ Office:
Signature over Printed Name

1.4 Description of NC/ OFI:

1.5 NC / OFI Acknowledged by (Auditee / Process Owner / Point Person):

Date Received:
____________________________________
Signature over Printed Name
 Form No. PG ComVal (DdO)_01 Rev 01

Section 2 : Necessary Action ( to be accomplished by Auditee / Process Owner)

2.1 Correction:

 Correction Target Completion Date:

2.2 Root Cause Analysis (RCA) using Fish Bone Diagram (attach diagram in a separate sheet).
Root Cause(s) Identified:

 Analyzed by:

2.3 Description of Corrective Action(s): (insert additional rows; use additional sheets if necessary)

Corrective Action (s) Responsibility Timeline

1
2
3
Approved by:
Date Approved:
____________________________________
Signature over Printed Name
Position Title

Section 3: Verification of Effectiveness (to be accomplished by Auditor / Initiator)

3.1 Results of Action Taken:

 Remarks (indicate if NC / OFI is considered closed or will require another verification):

Verified by: Verification Date:

Acknowledged by (Auditee / Process Owner): Next Verification Date (as appropriate):

 Form No. PG ComVal (DdO)_01 Rev 01

__________________________________________
Signature over Printed Name
Position Title

3.2 Results of Action Taken (as appropriate):

 Remarks (indicate if NC / OFI is considered closed or will require another verification):

Verified by: Verification Date:

Acknowledged by (Auditee / Process Owner): Next Verification Date (as appropriate):

__________________________________________
Signature over Printed Name
Position Title