Company Registration Office, ___________________

Doc. # 08-QSP-F-001 Corrective and Preventive Action Request/ Root Cause Analysis Form

CPA #: ______ (To be assigned by MR)

Section A (To be filled by the person who raises the CPA): Name & Designation: ________________________________________________________ CPA Type: Suggestion for Improvement Minor NC Major NC Customer Complaint CPA Source: Operations Inspection Internal Audit External feedback* * whether arising from complaints (online, offline, C&S Box), referral by an authority/other entity

Nonconformance/Problem Statement: __________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Signature: __________________ Date: _______________ Section B (To be filled by Person Assigned with the task of Analysis by MR): Assigned by MR for Analysis to: __________________________Target Date: __________ Root Cause(s): ____________________________________________________________

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Proposed Corrective Action(s): ________________________________________________

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Proposed Preventive Action(s): ________________________________________________

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Signature: __________________ Date: _______________

Section C (To be filled by MR): Corrective/Preventive Actions Considered: _______________________________________

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Assigned for Implementation to: ____________________ Target Date: _______________ Follow up (Date): _________________ Action Taken Effective In-effective In case Action is effective: CPA Close-out Date: _______________ In case Action is not taken or is in-effective: New CPA (Number): _________ Date: ______

MR Signature: __________________ Date: ______________