This document is a corrective and preventive action request form used to document issues found during an audit. It includes information such as the audit reference, date issued, CAR number, recipient, applicable procedure, description of the nonconformance, proposed corrective and preventive actions, completion date, and sign-offs from relevant parties to verify completion.

1. Rev. : 1
Doc. No. : 123 Rev. date : 15-Dec-09
Page 1 of 1
CORRECTIVE AND PREVENTIVE ACTION REQUEST FORM
Audit Reference : Date Issued : CAR No. : Reply due by :
Recipient :
Applicable Procedure : If CAR is from an internal audit, is it
CAR Issuer : Minor Major
(POTENTIAL) NON CONFORMANCE
Signed : Date :
CORRECTIVE ACTION
PREVENTIVE ACTION
Proposed Completion Date :
Signed (CAR Recipient) : Date :
ACTION COMPLETED/FOLLOW UP
Corrective / Preventive Action Verified as Satisfactory, completed, and implemented.
Signed (Quality Manger) : Date :
Signed (OD or MD) : Date :
Original to QA. department.