DIY Action Form

Use this form for nonconformity, corrective & preventive action. To raise an Action, fill in sections 1-2, sign, & forward to the QM.

1. What’s the issue, problem or improvement suggestion? (Person raising fills in)

Is there a short term fix or workaround?

2. Where did it come from (how identified)? (Person raising fills in)

A. AUDIT OR REVIEW?  B. SUPPLIER PROBLEM?  C. CUSTOMER COMPLAINT/FEEDBACK?  D. OTHER? 

Signature (person raising ): Date

Quality Manager only:

1 Serious nonconformance and/or high risk. Immediate action required. Action No:
2 Medium nonconformance and/or risk. Timely action required.
Issued for action to:

3 Issue is minor and/or risk is low.

Date:

3. Identify the cause(s) - what caused this? (Owner fills in)

4. What is the action plan – eg, improve, fix, prevent recurrence? (Owner fills in)
List each Action: Date by:

NB: if more space is needed, attach other sheets.

last modified: 25/08/10 page 1

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 DIY Action Form

5. What’s the result? (Owner fills in)

I confirm the action/s taken has satisfactorily resolved the issue/problem, and have allowed adequate time to verify it.

Closed by: Date of closure:

6. Is the problem fixed or the change satisfactory? (Reviewer fills in)

Yes / No (If not, say what other action is required.)

Note that if the review is done in, say a management meeting, you could delete this final box.

Signed Date

last modified: 25/08/10 page 2

49377047.docx