Initial Sample Inspection Report

General Information

Part Name & Number

Order Quantity

Delivery Quantity

Inspection Type

Reason for inspection during serial production

Reason for inspection before serial production


Scope and Extent of Inspection


Inspection Results
Released with stipulations (waiver required)
Rejected (re-sampling required)

Overall Disposition


Additional Comments

Name & Signature of Quality Inspector
Name & Signature of Customer Representative
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.