GANTA UNITED METHODIST HOSPITAL LABORATORY, NIMBA COUNTY

Corrective & Preventive Actions Report Form

Problem Statement/Nonconformity Observed

Initiated by: Date:

Reported to: Date:
Please complete the above and return the form to the Quality Manager.
□ Pre-analytical □ Analytical □ post-analytical
Assigned to: Date:
Immediate actions been taken:

Actual/Root Cause:

Signed: Date:

Corrective Action/Corrective Measure Executed:

Signed: Date:
Extent analysis:

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 GANTA UNITED METHODIST HOSPITAL LABORATORY, NIMBA COUNTY
Preventive Action executed \put in place:

Signature:__________________________________Date:______________________________
Effectiveness of Corrective Action:

Signed: Date:

Is the corrective and preventive action monitored for effectiveness?

YES NO if no state reason: -------------------------------------

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

All corrective actions completed ( ) Yes ( )No , comment due date ________ signed:__

Reviewed/ approved for closure ( ) Yes ( ) No, why?

Reviewed by:_____________________________________Date:___________________

Approved by:______________________________________ Date:__________________

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