Corrective Action Request Recommendation

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Complete this form to recommend the initiation of a corrective action request (CAR). If you have questions, contact Quality Assurance (John Gates, Ext. 106,

* = required field
Your Name *
Your E-Mail Address (if you want a copy of the CAR recommendation sent to you)
Recommendation Type * Corrective (non-conformance has already taken place)

Preventive (to prevent a non-conformance from taking place or for general improvement)

Recommendation Is Related To * Customer ("Customer Complaint"): Contact:

Vendor: Contact:

Internal Department:


Document Reference * Sales Order Number:

Job Order Number:

Purchase Order Number:

Other (describe):

What is the CAR recommendation? *
Related Quality Document and Paragraph * Quality Manual Section:

Operational Procedure:

Work Instruction:



Possible Root Cause

Did you ask "why" at least 5 times to arrive at the "best" root cause?
More on the 5 "whys":

Possible Corrective Action

Will this action correct the non-conformance that occurred?
Do affected departments agree with the corrective action?

Possible Preventive Action

Will this action ensure the non-conformance does not occur again?
Do affected departments agree with the preventive action?

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