# Corrective and Preventive Action (CAPA) Form

| Form ID | FRM-003 | Revision | 1.0 |
|---------|---------|----------|-----|

---

## Section 1: CAPA Identification

| Field | Entry |
|-------|-------|
| CAPA Number | |
| Date Initiated | |
| Initiated By | |
| CAPA Owner | |
| Target Closure Date | |

## Section 2: Classification

### Type
- [ ] Corrective Action
- [ ] Preventive Action

### Source
- [ ] Patient Safety Event
- [ ] Medication Error
- [ ] Healthcare-Associated Infection
- [ ] Equipment Failure
- [ ] Internal Audit
- [ ] External Audit/Survey
- [ ] Family Complaint
- [ ] Process Deviation
- [ ] Sentinel Event
- [ ] Management Review
- [ ] Other: ____________

### Priority
- [ ] Critical (patient harm occurred or high risk - 5 business days)
- [ ] Major (potential for patient harm - 15 business days)
- [ ] Minor (process deviation, no patient impact - 30 business days)

## Section 3: Problem Description

*(Describe the nonconformity or potential nonconformity - include patient impact if applicable)*




## Section 4: Immediate Containment

*(Actions taken to contain the immediate impact and protect patient safety)*




## Section 5: Root Cause Investigation

### Investigation Method Used
- [ ] Root Cause Analysis (RCA)
- [ ] Failure Mode and Effects Analysis (FMEA)
- [ ] 5 Whys
- [ ] Fishbone Diagram
- [ ] Fault Tree Analysis
- [ ] Other: ____________

### Root Cause Determination



### Contributing Factors



## Section 6: Corrective/Preventive Actions

| Action | Responsible | Due Date | Status |
|--------|-------------|----------|--------|
| | | | |
| | | | |
| | | | |

## Section 7: Staff Communication and Training

| Training/Communication Required | Target Audience | Completion Date |
|--------------------------------|-----------------|-----------------|
| | | |

## Section 8: Effectiveness Verification

| Criteria | Method | Result |
|----------|--------|--------|
| | | |

Verification Date: ____________
Verified By: ____________

## Section 9: Closure

| Role | Name | Signature | Date |
|------|------|-----------|------|
| CAPA Owner | | | |
| Quality Approval | | | |

### Lessons Learned



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*Form FRM-003 Rev 1.0*