CAPA Report Form
Originator's Name
*
First Name
Last Name
Email
*
Report date and time:
*
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Month
-
Day
Year
Date
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:
Hour
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01
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59
Minutes
Location
*
Identify Non-Conformance, Observation, Effectiveness through:
*
Master's/Supervisor's Review
Audit/Inspection
Incident Investigation
Risk Assessment
Customer
Employee
Safety Meeting
Management Review
Other
Policy / Procedure / Form Number
*
Describe Non-Conformance, Observation, Effectiveness:
*
Upload Reference Document?
*
Yes
No
Browse Files
Cancel
of
Include an Image?
*
Yes
No
Is there an Opportunity For Improvement (OFI)?
*
Yes
No
Recommend OFI (Corrective Action or Preventive Action)
*
Initials
*
*
I certify that the above information is true and correct.
Select Operations Manager or DPA for Review
*
VP Ops - Kent McGrath
Submit Form
Supervisor / Manager Review
Approve/Deny
*
APPROVED
DENIED
Describe Root Cause
*
Action Required
*
Notification to Originator
*
Comments
Provide feedback on Corrective Action of Preventive Action
In addition to Operations Manager/DPA, send record to:
*
QMR - Office@qsesolutions.com
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Rev.02 Date:01/21 ©QSE Solutions for Blue & Gold Fleet
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