RCA Form
The purpose of this is to identify the background situation of certain issues arising. This will also help the immediate team lead to assess and identify possible action plans in order to prevent such situations from happening again.
TL Name:
First Name
Last Name
Date
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Month
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Day
Year
Date
VA Name
Problem Statement
(Describe the incident or issue, including the scope and magnitude of the problem, in a clear and concise manner.)
Root Cause Identification
(Analyze the causal factors contributing to the incident. 5 Why technique must be employed to provide thorough background.)
Other Contributing Factors
(Examine the underlying factors that contributed to the root cause, including personnel, equipment, procedural, and organizational aspects.)
Action Plan
(Provide a plan for recommended corrective actions, including responsible parties, resources required, target completion dates, and methods for monitoring progress and effectiveness.)
Lessons Learned
(Ask the VA what lessons they have learned from the incident/s. Also include possible steps they could have taken to prevent the incident from occurring.)
Signature
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Should be Empty: