CORRECTIVE ACTION REQUEST FORM Clarksville-Montgomery ...

CORRECTIVE ACTION REQUEST FORMClarksville-Montgomery County School SystemCorrectionControl Number____________DateRec’d________Requester:_____________________ Dept.__________________ Date:_______________________Source: Please indicate by checking one of the following:[ ]Parent Concern [ ]Concern regarding Vendor Supplies or Services[ ]Process (Please use PUR-F009)[ ]External Audit [ ]Other (Specify)_____________________________SECTION 1: to be completed by requestorDescription of Problem: Be factual, objective, and concise and give traceability to issue for follow up.Attach any background information required for problem investigation and root cause determination.Please include recommendation(s) to solve the problem.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*Requestor, if this form is not being submitted electronically, please forward hard copy to: Tatiana Harris, ProcessManagement Coordinator, 621 Gracey Ave., Clarksville, TN 37040.Problem Owner:_______________________Dept. ________________ Respond by:__________________Problem Solver: _______________________ Dept. ________________SECTION 2: to be completed by Problem OwnerCorrective Action Response:Root Cause: (Problem solver investigates the problem and determines the extent/impact of the problem and itsroot cause. Problem Owner ensures that the root cause has been identified.)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________09/13/11, Rev. F PRM-F005 Page 1 of 2

CORRECTIVE ACTION REQUEST FORMClarksville-Montgomery County School SystemCorrectionControl Number____________DateRec’d________SECTION 3: to be completed by Problem SolverCorrective Action/Implementation Plan: Include training and communication requirements, documentationchanges and/or process/product/service changes.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Solver: Is a short term correction required before the long term action is implemented? If so, pleaseindicate what that will be.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Proposed/Planned Implementation Date of Corrective Action: _________________________Problem Owner: Initial_________Date__________Forward to Tatiana HarrisSECTION 4: to be completed by Process Management StaffAnswer received by Process Management Dept.:Implementation verified:Requestor satisfaction verifiedCorrective Action Closed and Problem Owner notified:Date ____________Initial_____________Date ____________Initial_____________Date ____________Initial_____________Date ____________Initial_____________NOTES:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________09/13/11, Rev. F PRM-F005 Page 2 of 2