| Customer & Location | Customer reference | |
| Supplier & Location | Supplier Reference | |
| Date of concern | 1 Team (Champion underlined) | |
| Part number & description | ||
| 2 Concern description |
| Containment within 24hrs |
3 Stock check | 5 Evidence Cut-off date/batch no./id |
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| Temporary counter measure | 5 Evidence Cut-off date/batch no./id |
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| Investigation within 5 days |
4 Root Cause | 5 Evidence Reason for non-detection |
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| Corrective action within 5 days |
6 Corrective Action Target Date for Completion |
5 Evidence Cut off date/batch no./id. |
Recurrence prevention (within 5 days) |
7 Make the solution standard
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5 Evidence Cut off date/batch no./id. |
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FMEA reviewed :
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| Actions completed (sign and print name) |
Date completed |