CPA Sheet

PT. X No. Form: QF. PDE. QA. 006 ( Rev. 0 ).

Corrective And Preventive Action ( CPA ) Date Approved Checked Written by

( Tindakan Perbaikan dan Pencegahan )

Seri Number Claim, No.: Copy Distribution/ Attention Review Date

Reg. No.: . . . . . / . . . . . / CPA/ . . . . ./ 200 . . . . Steping works: Examination Fix Counter Measure Action Solved Division Manager Staf

Problem title To/ Intern/ Supplier Corrective & Preventive Action ( 5W & 1H ) ; what, where, when, why, who & how. ?
Page : . . . . Of . . . .
Attention ( Problem solving should be done by cross functional team )
Part Name Found by/ at
No. Details Problem Caused Fixed Counter Measure PIC Due Date Status
Part no. Lot Product no.
Type/ model Quantity
Customer Ratio ( % )
Rough of sketch/ illustration or description of problem; ( Details of quality problem, required difference between
contents of defectives and specification, assumed cause, packing and palleting specifications , how it's found,
status, etc

Status Note:
Document has to be reviewed/ revised:
OK NG
Work instruction
Inspection STD/ QC system
Process control chart
PFMEA
Drawing
Other. Please specified :
This problem will be controlled on special attention, until ; weeks, month or year : Person In Charged of Dept.
Follow up of counter measure efectiveness
Weeks or month 1 st 2 nd 3 rd 4th 1 st 2 nd 3 rd 4th 1 st 2 nd 3 rd 4th 1 st 2 nd 3 rd 4th Sign Approval
Date/ month check
Qty check/ lot prod
Number of defectives ( . . . . . . . . .. . . . . . ) ( . . . . . . . . . . . . . . . ) ( . . . . . . . . . .. . . . . . ) (......... ...... ) (...............)
Judgement (Ok/ NG) Monitoring of check/ weeks/ month & Quantity check :
Confirmation of counter measure Closed by Quality Management Representative Control Date : Date : Date : Date :
Copy to:
Date : Corection ( v ) Result ( v ) Approved Approved Checked Prepared Point of No. No. Lot Result No. Lot Result No. Lot Result No. Lot Result
Status Status Status Status
QA Audit process Defectives Product. OK NG Product. OK NG Product. OK NG Product. OK NG
QC Required
OK 1
VERIFICATION

Prod No required 2
PD Others
NG QMR Division Manager Staf 3
PE Grade of problem : 4
Copy distribution :
Maint A = Serious/ safety 5
PPC Grade of problem Copy A B C 6
IC President/ Vice O B = Heavy 7
Mark. Director O O 8
General Manager O O C = Minor 9
Other Manager O O O 10
Total ASS Manager O O O Qty Sampling . . . . . . . Pcs Qty Sampling . . . . . . . Pcs. Qty Sampling . . . . . . . Pcs. Qty Sampling . . . . . . . Pcs.