Root Cause Analysis Form
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Minutes
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AM/PM Option
Describe the problem and the source
In this section, kindly define the nature of the problem.
Severity of the problem/issue
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5
Low
High
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
Client error
Staff related issues
Environment
Communication
Lack of information
Policies are not clear
Tools or equipment issues
Leadership problems
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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