Root Cause Analysis Form
Today's Date and time
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Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the problem and the source
In this section, kindly define the nature of the problem.
Severity of the problem/issue
Low
1
2
3
4
High
5
1 is Low, 5 is High
Provide the normal process
Please explain the normal flow or process on how to get the activity done without the problem occurring
Collection of data
Indicate here all related data that can be used in this root cause analysis
Events or Timeline
Risk factors
Rows
Yes
No
Remarks
Customer error
1
2
Staff related issues
3
4
Environment
5
6
Communication
7
8
Lack of information
9
10
Policies are not clear
11
12
Tools or equipment issues
13
14
Leadership problems
15
16
Cause and effect analysis
Look for the root cause using the data
Plans and goals
Implementation
Evaluation
What is the evaluation of the actions implemented? Are they related to the problems and to the plans? Are they effective? Kindly explain in paragraph format.
Documentation
In this section, explain what are the things that could be done and what are the lessons learned.
Investigative Team
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