Elimination Assessment Form
Assess a subject, item, or candidate using structured elimination criteria and record the final recommendation.
Subject Details
Subject/Case Name
*
Reference/Tracking Code
Category/Type Being Assessed
*
Please Select
Product
Service
Process
Sample
Site
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Elimination Criteria Assessment
Overall Fit / Viability
*
1
2
3
4
5
Elimination Status / Recommendation
*
Proceed
Hold
Eliminate
Criteria Evaluation
*
Rows
Meets Standard
Needs Review
Does Not Meet
Eligibility
1
2
3
Compliance
4
5
6
Performance
7
8
9
Risk
10
11
12
Documentation
13
14
15
Reviewer Notes and Outcome
Reviewer notes / rationale
Next action / follow-up step
Please Select
No further action
Retain for review
Request additional information
Schedule follow-up
Escalate to team lead
Other
Reviewer name or team/department
*
Submit
Should be Empty: