CAPA Report Form

Principal Investigator

Deficiency identified

Add photo evidence of deficiency if applicable

Response to deficiency

Corrective Action Plan (Action taken to correct specific deficiency identified)

Preventative Action Plan: (Action taken to prevent the recurrence of this problem in the future)

Signature of responsible personnel
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.