ML11327A021

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Dairyland Power Cooperative, La Crosse Boiling Water Reactor Possession-Only License No. DPR-45, Requested Procedure
ML11327A021
Person / Time
Site: La Crosse File:Dairyland Power Cooperative icon.png
Issue date: 11/14/2011
From: Brasel M
Dairyland Power Cooperative
To:
Document Control Desk, NRC/FSME
References
LAC-14198
Download: ML11327A021 (18)


Text

LA CROSSE BOILING WATER REACTOR (LACBWR)

DAIRYLAND POWER COOP E RAT IV E November 14, 2011 In reply, please refer to LAC-14198 DOCKET NO. 50-409 Document Control Desk U. S. Nuclear Regulatory Commission Washington, DC 20555-0001

Dear Sir or Madam:

SUBJECT:

Dairyland Power Cooperative (DPC)

La Crosse Boiling Water Reactor (LACBWR)

Possession-Only License No. DPR-45 Requested Procedure

Dear Sir or Madam:

Attached is Dairyland Power Cooperative's Administration Control Procedure 16.0, Corrective Action Program.

If you have any questions, please contact me at (608) 689-4220.

Sincerely, Michael A. Brasel Plant Manager, La Crosse Boiling Water Reactor MAB:jkl cc: Douglas Garner Security Specialist Office of Nuclear Security and Incident Response A Touchstone Energy Cooperative (It_*t.

S4601 State Highway 35 - Genoa, WI 54632-8846 ° 608-689-2331

  • 608-689-4200 fax www.dairynet.com

La Crosse Boiling Water Reactor I Page 0.1 ACP-16.0 LACBWR AnFMIN ISTRATIVE CONTROL PROCEDURE CORRECTIVE ACTION PROGRAM 4

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Page 0.2 ACP-16.0 LACBWR ADMINISTRATIVE CONTROL PROCEDURE CORRECTIVE ACTION PROGRAM Issue Notice No. 22 Dated AUG 1120 11 INSTRUCTIONS Description of and Reason for Change Clarify the responsibilities of AA, MQA and Plant Manager.

REMOVE AND INSERT ALL PAGES Add "Correct and Close" Level 3 CAR and delete CAR trending.

Remove CAP Coordinator title.

Changes to this procedure do not require 50.59 screening.

This issue shall not become effective unless accompanied by a new cover sheet, properly signed off in the appropriate review/approval columns.

ACP-16.0 Issue 22 LACBWR ADMINISTRATIVE CONTROL PROCEDURE CORRECTIVE ACTION PROGRAM 1.0 PURPOSE 1.1 This procedure describes the Corrective Action Program (CAP) utilized at the La Crosse Boiling Water Reactor (LACBWR) to identify, document, assign responsibility for, evaluate and resolve conditions adverse to quality. The program is also utilized to recognize opportunities for improving LACBWR processes, procedures and activities and to manage supplier issues identified during Quality Assurance (QA) and/or project overview activities such as audits, surveillances or shop visits.

2.0 SCOPE 2.1 This procedure applies to failures, malfunctions, deficiencies, deviations, defective material and equipment, including nonconforming materials, parts and components identified by LACBWR personnel during:

" Installation Activities 0 Incident Reports

  • Inspections 0 Licensee Event Reports
  • Testing 0 Radiological Occurrence Reports
  • Audits and Surveillances 0 Process Improvements
  • Design 2.2 ACP-17.3, "Maintenance Requests," requires malfunction Maintenance Requests (MRs) be periodically evaluated for potential trends. Noted trends with malfunction type MRs will be reported on a Corrective Action Report (CAR).

2.3 ACP-17.5, "Security Maintenance Requests" requires malfunction Security Maintenance Requests (SMRs) be evaluated annually for potential trends.

Noted trends with malfunction type SMRs will be reported on a Corrective Action Report (CAR).

2.4 Deficiencies identified at supplier facilities during a QA overview activity will be identified and tracked via the CAP until closure.

3.0 RESPONSIBILITIES 3.1 Assignee - Responsible for completing assigned corrective and/or preventive actions. This individual may be the same as the Dispositioner.

3.2 Administrative Assistant (AA) - Responsible for maintenance of the CAR tracking database, CAR status list and data compilation for CAR trending and point-of-contact for CAR status changes.

Page 1 of 15

ACP-16.0 Issue 22 3.3 Dispositioner - Responsible for proposing resolution of the issue reported on the CAR form. This includes reviewing the issue, performing detailed investigations or evaluations (when required), soliciting input from the appropriate supervisor and preparing a plan of action with milestones (when required) to address the identified issue. The Dispositioner may often complete the Apparent Cause Evaluation or Root Cause Analysis if required.

3.4 Engineering Staff - Responsible for reviewing conditions adverse to quality which involve design deficiencies to determine the cause of the condition and for recommending corrective action to resolve and/or preclude repetition.

3.5 Initiator - Responsible for reporting an opportunity for improvement or a condition adverse to quality on the CAR form. If the CAR is suspected to involve Safeguards Information, the Initiator shall immediately contact a Reviewing Official (RO).

3.6 Manager, Quality Assurance (MQA) - Responsible for assuring execution of the Corrective Action Program which includes concurrence with assigned CAR significance levels, concurrence with CAR dispositions, determination of nonconformances that qualify as a Significant Condition Adverse to Quality (SCAQ) and review of CAR closure. The MQA has stop work authority.

3.7 Operations Review Committee - Responsible for reviewing significant conditions adverse to quality and recommending corrective action. For project related SCAQ a Project Management team, at a minimum comprising an ORC Quorum shall be responsible for reviewing DCS Project related significant conditions adverse to quality and recommending corrective actions.

3.8 Plant Manager - Has overall responsibility for the Corrective Action Program which includes assignment of the CAR significance levels, assignment and review/approval of CAR dispositions and Dispositioner. The Plant Manager is also responsible for ensuring Safeguards Information documents/records produced or stored at LACBWR are protected in accordance with NRC regulations and this procedure.

3.9 Supervisor - Ensures that actions defined in the documented corrective actions have been accurately completed by the published date.

3.10 Verifier -Responsible for confirmation that approved dispositions and corrective and/or preventive actions have been accomplished. This responsibility is usually performed on a sampling basis by the Quality Assurance Department.

4.0 REFERENCES

4.1 DCS Quality Assurance Project Plan 4.2 DPC LACBWR Quality Assurance Program Description 4.3 ACP-03.1, Quality Assurance Overview 4.4 ACP-06.4, 10 CFR 50.59 Evaluations 4.5 ACP-07.6, 10 CFR 72.48 Evaluations Page 2 of 15

ACP-16.0 Issue 22 4.6 ACP-11.1, Inspections 4.7 ACP-17.1, Incident Reports Including Notification to the NRC 4.8 ACP-17.2, Reporting of Reportable Events 4.9 ACP-17.3, Maintenance Requests 4.10 ACP-1 7.4, Compliance with 10 CFR Part 21 4.11 ACP-17.5, Security Maintenance Requests 4.12 ACP-18.1, Collection, Storage and Maintenance of LACBWR Quality Assurance Records 4.13 HSP-01.2, Radiological Occurrence Reports 4.14 LACBWR Safeguards Information Program 4.15 LACBWR Extent of Conditions Guideline 4.16 LACBWR Root Cause Analysis and Apparent Cause Evaluation Guideline 4.17 LACBWR Timeliness Guideline 5.0 DEFINITIONS 5.1 Corrective Action Report (CAR) - A report documenting opportunities for improvement, discrepancies and non-conforming conditions. CARs have various significance levels, assigned by the Plant Manager and Manager, Quality Assurance. A CAR may need to be addressed by multiple action items, each of which need to be closed out prior to closing the original CAR.

5.2 Apparent Cause Evaluation (ACE) - An evaluation performed to identify the apparent cause(s) of a condition or event.

5.3 Root Cause Analysis (RCA) - An analysis that determines the fundamental cause that, if corrected, will prevent recurrence of a nonconforming condition or event.

5.4 Significant Condition Adverse to Quality (SCAQ) - A nonconforming condition that may exist in an item, system, program, process or procedure which renders the quality of an item or system unacceptable or indeterminate, and if uncorrected, could have a serious effect on safety or operability.

5.5 Correct and Close - A method used to close a Level 3 CAR which may require minor actions to resolve.

5.6 Extent of Condition - The generic implications of an issue, i.e., the potential or actual applicability to exist in other activities, projects, programs, facilities or organizations. Extent of condition evaluations should be governed by the complexity and/or nature of the issue (scope and issue description), the significance (issue category type), and cause(s).

5.7 Nonconforminq Condition - A deficiency in characteristic, documentation or procedure which renders the quality of an item unacceptable or indeterminate.

Page 3 of 15

ACP-116.0 Issue 22 Examples of nonconformances include physical defects, incorrect or inadequate documentation or failure to comply with prescribed processing, inspection and procedures.

5.8 Opportunity for Improvement - An identified issue or suggestion to improve or enhance a process, activity or system that is not considered a nonconforming condition or deviation, but may require action to prevent one from developing.

6.0 PREREQUISITES 6.1 Not applicable.

7.0 PRECAUTIONS 7.1 Security related conditions adverse to quality may be Safeguards Information (SGI) and it must be handled properly (see 4.14). If the CAR is suspected to involve Safeguards Information, the Initiator shall immediately contact a Reviewing Official (RO).

7.2 If conditions exist where immediate corrective actions are necessary, the actions taken shall be documented in the initiation section of the CAR.

8.0 PROCEDURE 8.1 General 8.1.1 The identification of issues is the responsibility of all LACBWR personnel.

8.1.2 The corrective action process begins with the identification of an issue, involves problem investigation and/or evaluation, corrective and/or preventive action(s), and follow-up action to verify that corrective action has been thoroughly implemented. It concludes with documenting the closure action. A flow chart of the process is included as Attachment 1, "Corrective Action Process Flowchart".

8.1.3 A graded approach is utilized in the identification and resolution of issues. CARs are classified in the following levels:

a) Level 1 - A significant nonconforming condition that is treated as a Significant Condition Adverse to Quality (SCAQ).

b) Level 2 - A nonconforming condition that adversely affects the technical or quality acceptability of an item or process.

c) Level 3 - A minor deficiency which is an unintentional or isolated departure of a characteristic or action from a specified requirement. Once resolved, these discrepancies can be treated as "correct and close" issues and closed.

d) Level 4- An opportunity for improvement.

8.1.4 Issues are recorded on a CAR form. See Attachment 2, "Corrective Action Report" form.

Page 4 of 15

ACP-1 6.0 Issue 22 I 8.1.5 Deficiencies identified during fabrication, assembly, or testing of systems must be resolved prior to use of the item.

8.1.6 For issues noted during the conduct of an audit or surveillance, QA personnel shall be the initiator of the CAR with notification to the Plant Manager.

8.2 Initiation CAUTION: If the issue requires immediate corrective action, the Plant Manager and MQA shall be notified.

8.2.1 Upon determination of a possible issue, the Initiator shall initiate a CAR. The Initiator is to complete the "INITIATION: PART I" portion of the CAR Form. The Initiator shall:

a) Identify the Initiator, initial and date b) Create a succinct but descriptive title for the CAR c) Describe the issue in sufficient detail (see 8.2.2) d) Document applicable reference documents e) Stamp the completed "INITATION" portion of the CAR form "ORIGINAL" NOTE: The completed part(s) of the CAR is an "Original" and is to be retained in the CAR binder.

8.2.2 The description of the issue shall be in sufficient detail to permit disposition and initiate proposed corrective and/or preventive action(s).

The Supervisor of the affected area or process should work with the Initiator to include the following information:

a) Documents and process(es) involved b) Specifics of the issue, including the precursor chain of events c) Design or construction impact 8.2.3 When required, contact the Supervisor of the affected area or process to determine the validity and applicability to the Corrective Action Program and provide feedback to the Initiator to assure clarity of the issue identified.

8.2.4 For QA surveillance and audit findings, the MQA shall determine the validity and applicability to the Corrective Action Program and provide feedback to the Initiator to assure clarity of the issue indentified. The Lead Auditor shall complete the "INITIATION: PART I" portion of the CAR form in the manner previously described with direction from the MQA, as necessary.

Page 5 of 15

ACP-16.0 Issue 22 8.2.5 Upon completion of "INITIATION: PART I", the Initiator shall obtain the next available CAR number from the CAR book and place it on the CAR form and submit it to the Plant Manager for approval.

8.2.6 The Plant Manager and MQA will review the drafted CAR to determine the completeness and validity of the issue. Upon their concurrence, the following determinations will be documented on the "INITIATION: PART IH"section of the CAR:

a) Level of significance (1, 2, 3 or 4) b) Root Cause Analysis Required (Yes/No) c) Apparent Cause Evaluation Required (Yes/No) d) 10CFR50.59 Screening Required (Yes/No) e) 10CFR72.48 Screening Required (Yes/No) f) 10CFR Part 21 Applicable (Yes/No)

NOTE: CARs, for which 10CFR Part 21 reportability is considered to be potentially applicable, immediately refer to ACP-17.4 and then continue processing the CAR.

As required, personnel will be assigned to perform b), c) d) or e) in step 8.2.7.

8.2.8 For Level 1 SCAQ CARs, a Root Cause Analysis (RCA) is required.

8.2.9 For Level 2 CARs, the Plant Manager and MQA shall determine if an evaluation is required. If so, an Apparent Cause Evaluation (ACE) shall be indicated.

8.2.10 The Plant Manager and MQA shall determine if a disposition of the CAR is required, or if the CAR will be "correct and close".

a) If the CAR requires a disposition, the Plant Manager shall determine the appropriate person to disposition the CAR based upon the nature of the issue. The Dispositioner's name shall be entered on the CAR with a due date.

b) If the CAR is a "correct and close", the Plant Manager shall check this on the CAR form. When it is determined that the action(s) required to resolve a Level 3 CAR are completed, the CAR may be closed and submitted to the AA for entry into the CAR database.

c) Upon completion of the above a) or b), the Plant Manager and MQA shall sign and date the Initiation Part II of the CAR.

8.2.11 If a detailed disposition is required (for Level 1 and 2 CARs), the Plant Manager or MQA shall provide the CAR to the AA for processing, filing and notifying the next person assigned to complete the disposition.

Page 6 of 15

ACP-16.0 Issue 22 8.3 Disposition 8.3.1 When required, the Dispositioner shall review the description of the issue and perform investigations or evaluations, as appropriate, in order to prepare a disposition. The investigation shall include determination if similar occurrences have taken place in the past. If similar occurrences have been noted, the issue shall be returned to the Plant Manger and MQA to determined need for an ACE and elevation of CAR level.

NOTE: The disposition shall be completed, generally, within 14 days of assignment.

8.3.2 Upon completion of the initial investigation, the Dispositioner shall document applicable information in the "DISPOSITION: PART I" section of the CAR:

a) A proposed disposition summary shall be provided to define the plan for resolution of the issue(s).

b) The summary shall be supported by specific corrective action(s).

The corrective action plan shall include the tasks necessary to bring a nonconforming condition into compliance, and when applicable, to prevent recurrence of the nonconforming condition.

c) Each proposed corrective action shall be described in detail along with actual or scheduled completion dates. Corrective actions need not be completed prior to submitting the disposition.

d) For Nonconformances (Level 1 or 2), the disposition shall determine the extent of condition, its cause, its effect, and when required, actions to prevent recurrence.

NOTE: When required, the Root Cause shall determine the action(s) required to eliminate or correct the cause. When required, an ACE may be used to identify the apparent cause. Appropriate forms shall be used to document Root Cause Analyses and Apparent Cause Evaluations. (see applicable guideline for assistance.)

8.3.3 The Dispositioner shall stamp the "DISPOSITION" section of the CAR as "ORIGINAL" and submit to the Plant Manger for review/approval.

NOTE: Operations Review Committee review and approval is required for SCAQ CARs. Conditions adverse to quality which involve design nonconforming conditions shall be reviewed by the Engineering staff to determine the cause of the condition and for recommending actions to preclude recurrence.

Page 7 of 15

ACP-16.0 Issue 22 8.3.4 If the disposition is not acceptable, the Dispositioner shall be notified by the Plant Manager and provided with the reason for rejection. The Dispositioner shall provide a revised disposition. The original disposition shall be attached and remain as part of this document.

8.3.5 The Plant Manager shall determine the appropriate person (Assignee) for corrective action completion. The Plant Manager shall note the number of the specific corrective actions, document the Assignee's name, determine a due date for completion, and notify the Assignee of assignment(s).

8.3.6 The disposition and its corrective action implementation schedule shall be planned along with other assignments, and realistic completion dates shall be established.

8.3.7 Complex corrective actions may require a long term schedule to fully implement. Once the immediate corrective actions to bring the issue into compliance are completed, long term corrective actions to prevent recurrence may be entered into the project schedule or ORC/SRC Tracking list and closed.

8.3.8 Items shall be repaired or reworked only in accordance with approved procedures or instructions and shall be inspected after repair by Quality Assurance personnel in accordance with the work control process.

8.3.9 Items which are accepted for use with a known deficiency shall be fully documented with the specification requirement, justification for acceptance, and effect of such use.

8.3.10 The disposition shall be approved by the Plant Manager and MQA and given to the AA for entry into the CAR database. The AA shall return the hard copy of the "DISPOSITION" to the CAR binder upon completion.

8.4 Completion 8.4.1 The Assignee shall ensure that the corrective action has been implemented by the scheduled completion date and document completion of action in the "COMPLETION: PART I" section of the CAR.

NOTE: Actions not finished by the scheduled completion date will be elevated to the Plant Manager for attention and action. An extension for adue date for a Level 1 or 2 CAR, will require documented authorization from the Plant Manager and MQA.

8.4.2 A separate "COMPLETION" page shall be initiated for each corrective action. If additional space is needed, additional pages may be attached, but the "COMPLETION" section of the CAR form should always be used to document corrective action.

8.4.3 The Assignee shall include the Action #, Action Title and Due Date on each "COMPLETION" page.

Page 8 of 15

ACP-16.0 Issue 22 8.4.4 A copy of the "INITIATION" and "DISPOSITION" sections of the CAR may be used for "Information Only" when routing the "COMPLETION" portion of the form for signature approvals.

8.4.5 When a corrective action is completed, the Assignee shall sign and date the "COMPLETION: PART I" section of the form, and stamp the document "ORIGINAL".

8.4.6 For Level 1 or 2 CARs, the Assignee shall deliver the original "COMPLETION" form and supporting documentation to his/her supervisor, prior to or on the corrective action due date. A copy of the "INITIATION" and "DISPOSITION" sections of the CAR may be used as

'Information Only'.

8.4.7 The Supervisor shall verify the corrective action has been acceptably completed. If the corrective action is not acceptably completed or is not yet complete, the CAR shall be returned to the Assignee for further action.

8.4.8 The Supervisor shall verify all supporting documents are attached to the CAR prior to approval.

8.4.9 Once supporting documentation and acceptable completion are verified, the Supervisor shall provide signature approval on the original "COMPLETION: PART I1".

8.4.10 The Supervisor shall deliver the "COMPLETION" documentation to the AA.

8.4.11 The AA shall update the completed corrective action in the CAR database and notify Verifier (QA) of the completed status of the corrective action.

8.4.12 When all corrective actions defined in the disposition are acceptably completed, the AA shall update the CAR database and notify the Verifier that all Level 1 and 2 CAR action items are complete and the CAR is ready for verification.

8.5 Verification 8.5.1 QA (Verifier) shall independently verify that the Level 1 and 2 CARs corrective and preventive actions have been acceptably completed.

8.5.2 The "VERIFICATION" section of the Level 1 or 2 CAR form shall be stamped "ORIGINAL" by the Verifier.

8.5.3 If corrective actions are not complete, the Verifier will note it in "VERIFICATION: PART I" and the CAR will be returned to the Supervisor for action.

8.5.4 For acceptably completed CARs, Verifier will sign and date the CAR in the "VERIFICATION: PART I" of the CAR form and return it to the AA.

Page 9 of 15

ACP-16.0 Issue 22 8.5.5 QA will assess Level 3 CAR closure via periodic surveillance of selected closed CARs.

8.6 CAR Closure 8.6.1 The AA shall ensure that all CAR documentation is complete.

8.6.2 The AA shall document the date the CAR record was sent to file in the "VERIFICATION: PART I1"section of the CAR and sign and date the "VERIFICATION: PART I1"section.

8.6.3 The AA shall update the database with CAR closure information and file the document as a record in accordance with reference 4.12.

9.0 RECORDS 9.1 All records generated using this procedure will be maintained in accordance with ACP-18.1.

9.2 Records generated through implementation of this procedure include:

9.2.1 Attachment 2 - Corrective Action Report 10.0 ATTACHMENTS 10.1 Attachment 1 - Corrective Action Process Flowchart 10.2 Attachment 2 - Corrective Action Report Page 10 of 15

ACP-16.0 Issue 22 CORRECTIVE ACTION PROCESS FLOWCHART Attachment 1 (Page 1 of 1)

Assign Dispositioner and due date on CAR Form (Level 1 & 2) and submit to AA.

(Plant Manager and MQA)

Page 11 of 15

ACP-16.0 Issue 22 CORRECTIVE ACTION REPORT Attachment 2 (Page 1 of 4)

Initiator: Initial/Date: CAR No.:

CAR

Title:

Reference I Documents:

L." -*i*q ;**' -.* 'a .,*.¢ : :'*;!'.*' .  ; ',: .. "7r;'"- ,,.. *-: ? :7* ** '*.7****7*: J *" :* *- **' , * ,'- .r._" ,"4?,* o El Level 1 Root Cause Analysis Required? [I No El Yes, Assigned To:

Issue Significance 0 Level 2 Apparent Cause Evaluation Required? EU No El Yes, Assigned To:

Level: 0 Level 3 10CFR 50.59 Screening Required? [I No EUYes, Assigned To:

El Level 4 10CFR 72.48 Screening Required? Ul No [I Yes, Assigned To:

10CFR 21 Applicable? [I No 0 Yes Determination of Disposition: [I Disposition Required 0 Complete and Close (No Disposition Required) (Level 3 Only)

Person Assigned to Disposition: Due Date:

Plant Manager:

Signature Date Manager, Quality Assurance:

Signature Date Page 12 of 15

ACP-16.0 Issue 22 CORRECTIVE ACTION REPORT Attachment 2 (Page 2 of 4)

D~ISPObSITION:P~ ,o~

Date: Dispositioner: CAR No.:

Proposed Disposition

(

SUMMARY

):

(Attach additional sheets if necessary.)

.... ............ . .. * . ... ... ... . ... . ... .i~~",Proposed",:

1. .posed-Corrective Action (Detai!ed) . DueDate 01 02 Suggested Corrective Action(s):

(Attach additional 03 sheets if necessary.)

04 05 Proposed Disposition Approved? 0l Yes El No, because:

Determination of Corrective Action Required: El Action El Complete/Close (No Action Required)

Action #: Assignee: Due Date:

Action #: Assignee: Due Date:

Action #: Assignee: Due Date:

Action #: Assignee: Due Date:

Action #: Assignee: Due Date:

Plant Manager Signature Date Manager Quality Assurance Signature Date Page 13 of 15

ACP-16.0 Issue 22 CORRECTIVE ACTION REPORT Attachment 2 (Page 3 of 4)

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Date: Assignee: CAR No.:

Action #: Action

Title:

Due Date:

Corrective Action Completed:

(Attach additional sheets if necessary.)

All required close-out documentation has been attached.

Assignee:

Name Signature Date Supervisor:

Name Signature Date Page 14 of 15

ACP-16.0 Issue 22 CORRECTIVE ACTION REPORT Attachment 2 (Page 4 of 4)

VE RIFIATION of CAR

~ F A ~PAR~T o IetedbyoAPers ne CAR No.

Corrective Action Verified:

(Attach additional sheets if necessary.)

Verified By:

MQAorQAD Name Signature Date Sent to File:

Name Signature Date Page 15 of 15