CORRECTIVE / PREVENTIVE ACTION

REPORT

Nama Proyek / Project Name KODE / NOMER SERI :

NCR CODE / SERIAL NUMBER :

CORRECTIVE ACTION PREVENTIVE ACTION

STEP 1 : IDENTIFICATION

ISSUER
Company /
Subcontractor:
Name: Position: Date: Signature:
Situation (NCR or
potential NCR)
needing Corrective or
Preventive Action:
Works
concerned:

Relevant NCRs
(if any):
ROOT
CAUSE(S):
STEP 2 : ANALYSIS OF
CAUSES AND ACTION

CORRECTIVE /
PREVENTIVE
ACTION TO BE
TAKEN (based
on the analysis
of the causes):
DEADLINE FOR IMPLEMENTATION OF ACTION:
Person Responsible for Action: Name: Position:
Name:
APPROVAL
STEP 3:

Position:

Date:
Signatur
e:

ACTUAL DATE OF ACTION TAKEN:

Person Responsible for Action: Name: Date: Signature:

STEP 4 : VERIFICATION &

Please attach evidence of action taken, for final closure.

EVALUATION

Assessment of the effectiveness of the action (the evaluation should be performed within an
agreed period of time as specified in the relative procedure):

0 (not effective) 5 (very effective)

Comments:

Name: Position: Date: Signature:

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