Corrective Action Request Form

• Company

• Address
  Address

• Supplier

• Address
  Address

• Quality Manager

• Date issued

  Date

Corrective Action Request

• Instructions:
  1. Indicate the product name, lot/batch number, and date received.
  2. Select the source of the need for corrective action to be taken.
  3. Take/attach photos and create an action where you can specify the details of the corrective action and set the assignee, priority level, and due date.
  4. Sign off with your digital signature to complete the corrective action request.

• Reference product name

• Lot/batch number

• Date received

  Date

• Source

  Select Internal Complaint Audit Quality assurance inspection Production test failure Nonconformity Other

  • Internal Complaint
  • Audit
  • Quality assurance inspection
  • Production test failure
  • Nonconformity
  • Other

• Specify major/minor product nonconformity

• Identify person

• Test type

  Appearance

  Dimensional

  Functional

  Other

• Product result

  Pass

  Fail

• Specify

• Take/attach relevant photos and create an action

  Media

Completion

• Additional comments

• Quality Manager Name & Signature

  Sign