Form Number: Click here to enter text. Issuer: Click here to enter text. Date of Issue: Click here to enter text.

Reference/Source of Issue: Click here to enter text.

Form Type:

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Priority Level: Choose an item.

IR Assigned to: Click here to enter text. Date Notified: Click here to enter text.

Estimated Date of Completion: (To be completed by person assigned the IR) Click here to enter text.

Challenge or Non-Conformance: (To be completed by Issuer)

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Existing Requirement(s) if any: (To be completed by Issuer)

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Root Cause:

(To be completed by person assigned the IR, and to be completed for all NC’s, Minor NC’s, CA’s and PA’s. Explain: What was the true cause of the issue?)

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Actions Taken to Correct the Issue:

(To be completed by the person assigned the IR. Explain the immediate action taken to address/fix the issue, timeline to address, etc.)

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Corrective Action(s):

(To be completed by the person assigned the IR. Explain how the action taken will stop the long-term reoccurrence of the above cause.)

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Ready for Verification (Name):Click here to enter text. Date Submitted for Verification: Click here to enter text.

Verification of IR - to be completed by Verifier

Verifier Name: Click here to enter text.

Date: Click here to enter text.

Completed: Choose an item.

Effective: Choose an item.

Recommended for Closure: Choose an item.

Re-verification needed: Choose an item.

Needs re-assigned to: Click here to enter text.

Re-verifier’s Name: Click here to enter text.

Date Re-verified: Click here to enter text.

Effective: Choose an item.

Recommended for Closure: Choose an item.

Verifier Comments:

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