PT.

AKURA BINA CITRA

CORRECTIVE AND PREVENTIVE ACTION REQUEST FORM
CPAR No. #016/2018 SPK No. # Internal Quality Audit
Date Issued: Requested Company/ by: Issued to (company or title): Target of Response Time:
November 10, 2018 QHSE FS December 10, 2018

Affected Department /
FS
Person In Charge
No copy of calibration certificate were available.
Problem Description
Ex.: Light meter SO1-ABC-05, Profile Gage S03-ABC-031
v Service System Part / Equipment
Internal Audit:
Customer Complaint:
Contract / Work Order No:
Reference Detail
Purchase Order No.:
(Fill where applicable)
Inspection Report No.:
Part/Equipment No.:
Other:
Reference Standard /
Procedure
Gauge Room Controller did not update the distribution of copies of calibration
Cause of Problem
certificate
Action Needed Corrective Action Preventive Action
Completion Date:
Sending copy of available calibration certificate
Corrective / Preventive
Action Evidence Document:
(Use other paper if it is not
sufficient)

Completion Date:
Action to prevent
recurrence / occurrence Induction to Gauge Room Controller for always update
of problem Evidence Document:
distribution of copies of certificate (using soft copy)
(Use other paper if it is not
sufficient)

Proposed by, Reviewed and Approved by, Closing Out Verified by,

Name: Asep Sudrajat Name: Andi Setyo Budianto Name: Andi Setyo Budianto
Position: Deputy Position: QHSE Manager Position: QHSE Manager
Date: December 09, 2018 Date: December 12, 2018 Date:

Management of Change : Yes No Effective Date :

Verified by
Reviewing the
effectiveness of corrective Date Verification
/ preventive action
Remarks Effective / Not Effective / Repetitive

Additional Notes
Form No.: 6.4 Rev. No.: 01 Date Issued : 05/01/2015