Root-Cause Analysis
Issue Details
Date issue reported

Brief description of the issue

Rate the impact to productivity

Possible Root Cause

List potential reasons why the issue happened


Brief description of a cause

Rate probability as the root cause

What is the root cause of the issue?

Categorize the root cause of the issue

Please specify

Prevention Strategy

Solution to be implemented

Estimated cost

Are there special considerations?

Please specify

Are there incidental findings to be reviewed for corrective action?

Please specify

Full Name and Signature of RCA Team Leader

List RCA Team Members

Full Name and Signature
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.