Action Request
Date: AR Number:
AR Source: Internal Customer Supplier (Name:) Deselected
Action type: Root Cause and Corrective Action (CAR) Correction Only (CO) Deselected

RESULTING FROM
Risk Assessment
Customer Complaint
Negative Performance Trend

Audit Finding
Internal Audit
External Audit
Customer Audit (Name:)
Classification:
Major Minor
OFI Deselected
Deselected
Management Review Action Item
Product Nonconformance (Complete Disposition Section)
Other (FOD, Calibration, etc) :
Deselected

Issued By: Issue Date:
Issued To: Response Due By:

DETAILS:
(Utilize this section as applicable)
Customer:
Return #: RMA #:
Qty Shipped: External Qty Rejected:
Internal Qty Rejected:
Description:
Part #: Revision:
Work Order #:
Original PO: Original Line #:
Return PO: Return Line #:

CONDITION: (CAR &CO)
(Detailed description of why a corrective action request has been initiated.)
Risk Rating of Reported Condition:
High (significant impact of product, process, quality / delivery schedules, customer, and other areas)
Medium (slight impact possible for product, process, quality / delivery schedules, customer, and other areas)
Low (very small potential for impact to product, process, quality / delivery schedules, customer, and other areas)
Deselected

IMMEDIATE, CONTAINMENT ACTIONS / CORRECTIN: (CAR & CO):
(Actions taken to immediately correct the reported condition and to determine if similar nonconformities exist)

DISPOSITION - For Product Nonconformance
Disposition Notes:
Disposition Type:
Return to Supplier
Rework
Scrap
Use-As-Is (Customer Approval Required)
Deselected
Comments:
Authorized Name: Date:

ROOT CAUSE ANALYSIS: (CAR)
(Determine root cause of the reported condition, typically "5 why" method [all 5 not required].)
WHY (did the condition occur)?
WHY (did that occur)?
WHY (did that occur)?
WHY (did that occur)?
WHY (did that occur)?
ROOT CAUSE STATEMENT:
Related to Human Factors?

CORRECTIVE ACTION: (CAR)
(Actions taken to correct the root cause of the condition and prevent future occurrences.)
Name: Title:
Date: Implementation Date:

APPROVAL: (CAR)
Accept Reject Deselected Rejection Notes (only if Action Request response is rejected):
Name: Date:

FOLLOW UP & CLOSURE: (CAR & CO)
(Activities performed to ensure the proposed actions have been taken, implemented, and effective. Comment boxes for each area should be completed to details what was done, and justification for closure or additional actions needed)
Follow Up Notes:
Closure Justification: (CAR & CO)
Remain Open (Not Implemented as Planned)
Close Action (Actions Taken as as Planned)
Deselected
Comments:
Effectiveness Justification: (CAR & CO)
Effective (Actions Determined Effective, No repeat Occurence)
Not Effective (Actions Not Effective / Effectiveness Unknown)
Deselected
Comments:
Adjusted / Mitigated Rating: (CAR)
High (Significant Risk Remains: Additional Actions Needed)
Medium (Very Slight Risk Remains: Actions Not REQUIRED, but suggested)
Low (No Additonal Actions Requried)
Deselected
Comments:
Name: Date:

FOLLOW UP & CLOSURE: (CAR & CO) - As Needed
(Activities performed to ensure the proposed actions have been taken, implemented, and effective. Comment boxes for each area should be completed to details what was done, and justification for closure or additional actions needed)
Follow Up Notes:
Closure Justification: (CAR & CO)
Remain Open (Not Implemented as Planned)
Close Action (Actions Taken as as Planned)
Deselected
Comments:
Effectiveness Justification: (CAR & CO)
Effective (Actions Determined Effective, No repeat Occurence)
Not Effective (Actions Not Effective / Effectiveness Unknown)
Deselected
Comments:
Adjusted / Mitigated Rating: (CAR)
High (Significant Risk Remains: Additional Actions Needed)
Medium (Very Slight Risk Remains: Actions Not REQUIRED, but suggested)
Low (No Additonal Actions Requried)
Deselected
Comments:
Name: Date:

STATUS
(Current Status of the Action Request / Enter Name & Date upon closure.)
Status:
Open
Pending
Closed
Comments:
Authorized Name: Date: