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Corrective Action (CAPA) Form

Corrective and preventive action record: track issues from identification to verified closure

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PAGE 1 OF 2

CAPA Details

CAPA ref #

Date raised

Raised by

Department

Priority

Due date

Non-Conformance / Issue Description

Source

Audit finding Incident investigation Customer complaint Inspection Management review Other:

Immediate Containment Actions

#	Action	Owner	Date Completed
1
2
3

Root Cause Analysis

METHOD: 5 Whys Fishbone Fault tree Other:

Corrective Action (CAPA) Form - Page 2 of 2

CAPA ref

Date

Corrective Actions

#	Action	Owner	Due Date	Status
1
2
3
4

Preventive Actions

#	Action	Owner	Due Date	Status
1
2
3

Verification

Verified by

Date

Evidence of completion

Effective

Effectiveness Review

Review date

Reviewed by

Issue recurred

Notes

Approval

Raised by — Signature

Print name

Date

Approved by — Signature

Print name

Date

Closed by — Signature

Print name

Date

Declaration

I declare that the information recorded in this CAPA form is accurate and complete. All corrective and preventive actions have been implemented, verified and reviewed for effectiveness. This CAPA is now closed.