Section 1 – To be filled out by OriginatorDate: MM slash DD slash YYYY Originator:Category – Check One Employee Suggestion Maintenance Safety/Housekeeping Calibration Assessment Document Change Request OTHER Preventative ActionReference and Description of Problem or Condition (Please be specific and include a description of the item/process affected such as Job #, Form #, Procedure, Location, or other as appropriate):Section 2 - To be completed by a member of the Management Team and AssigneeApproval and Date:Assignee:Due date:Apparent Cause:Corrective and/or Preventive Action:Assignee Signature:Date: MM slash DD slash YYYY Section 3 - Follow-Up after Corrective/Preventive Action implementationFollow-Up Approval and Closeout (Signature & Date of Mgt. Team and Representative of affected department)Mgt. Team SignatureDate MM slash DD slash YYYY Representative SignatureDate MM slash DD slash YYYY This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
