Quality - Non-Conforming / Incident Investigation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Investigation Report

• Food safety incident is an incident which has the potential to cause injury, illness or death. These types of incident are likely to affect consumers and customers, disrupt business and may have an adverse impact on GF's reputation.

• 1.0 Site

  Select

• 2.0 Incident Number

• 3.0 Source

  Site

  Customer

  Regulatory

  Other

• 4.0 Date of Incident

  Date

• 5.0 Time of Incident

  Date

• 6.0 Product Description

• 7.0 Batch Code (s) (Best Before/Use By)

8.0 Overview

• Nature of Incident

• Hazard Type

  Physical

  Chemical

  Micro

  Quality

  Regulatory Compliance

• Is the Incident Contained ?

  Safe

  At Risk

  N/A

• Are we rejecting product ?

  Yes

  No

  N/A

• Amount of product rejected.

• Cause of the issue.

• Root Cause

• Overall Risk Score

  Low

  Med

  High

• Corrective Actions

• Preventive Actions

• Description of event

• Add Photos as required

  Media

9.0 Team Members Involved in Investigating the Incident

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

• Name and Sign

  Sign

10.0 Investigation Summary

• Summary

• Photos as reqd

  Media

11.0 Capture Facts

• What do you know for certain ?

• Evidence

• Photos as reqd

  Media

12.0 Consolidate Assumptions

• What do you believe has occurred or contributed to the situation ?

13.0 Root Cause

• Detail the System that failed

14.0 Potential Risk

• 

• What is the Likelihood ?

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• What is the consequence ?

  Insignificant

  Minor

  Moderate

  Major

  Catastrophic

• Overall Risk Score - as per risk assessment table.

  Low

  Medium

  High

  Extreme

15.0 Corrective Actions

• Actions taken immediately to rectify the problem. Include Person Responsible

• Actions taken immediately to rectify the problem. Include Person Responsible

• Actions taken immediately to rectify the problem. Include Person Responsible

• Name and Signature of person responsible to ensure actions are carried out.

  Sign

16.0 Preventive Actions

• Medium and Long Term Action required to prevent a repeat incident.

• Medium and Long Term Action required to prevent a repeat incident.

• Medium and Long Term Action required to prevent a repeat incident.

• Name and Signature of person responsible to ensure actions are carried out.

  Sign

17.0 Report Date

• Date of Report

  Date

18.0 Investigated By:

• Name and Signature of Lead.

  Sign

• NB:
  1. Treat with Urgency.
  2. Site QA to complete Serious Incident Report within 2 hours of incident and send to designated National QA representitive.
  3. National QA representative is to circulate the Serious Incident Inter Company Investigation alert to all GF sites and relevant Senior Executives as appropriate and maintain investigation records. Note: where a Product Withdrawal or Recall is initiated the Group Quality Director will review the alert prior to circulation.
  4. Investigation documentation is to be attached to the NCR in the Non-Conformance database.

Serious Incident - Inter Company Investigation

• Can this happen at your site ?<br>If No , record why this cannot happen at your site.

  Yes

  No

  N/A

• If the same incident can occur on your site then complete the following fields.

• Investigation details: Record details of the site investigation carried out.

• Name and signature of person who investigated the incident at your site.

  Sign

• Record any action taken to prevent occurrence:

• Record preventative action to be taken to prevent occurrence.

• Report date

  Date

• Name and Signature of person who has completed this report.

  Sign