XXXX Design-Build Project

S.P. XXXXX
QUALITY MANAGEMENT PLAN

{Contractor}
Form.: QM501FA

Rev. 0

{date}

Page 1 of 1

NONCONFORMANCE REPORT
1. NCR Control No.:

2. (Sub)Contractor/Supplier:

5. Location:

3. Originator & Organization:

6. Originator:

4. Date:

7. Specification Section & Drawing No.:

8. Contract Requirement:

9. Nonconformance Description:

10. NCR Required?: Yes

No
11. Reply requested from:
______________________________________
Quality Assurance Signature
13. Root cause of the problem and action(s) to prevent recurrence:

12. Need Date:

14. Proposed Action(s):

15. Disposition status:

Reject Work

Rework

Repair

Revise

Replace

Redo

17. Disposition Prepared By:

Signature

Use-As-Is

16. Notice of Design Change

Required?
Yes
No

18. Design Engineer Approval: (for Construction Repair and Use-As-Is status)

Date

Print Name

Signature

Date

Concurrence of Corrective and Preventive Actions:

19.

Originator

Date

20.

Quality Assurance Signature

Date

21. Mn/DOT has reviewed the above and accepts the NCR proposed disposition and/or corrective measures.
Print Name

Signature

Date

22. Quality Manager verification that nonconforming condition has been corrected:
Verified By:
Print Name

Signature

MnDOT Design-Build Quality Template (June, 2011)

Date