COMUSFLTFORCOMINST 4790.

3 REV B

SURVEILLANCE/MONITORING/AUDIT DISCREPANCY RECORD

QA FORM 14
1. ITEM 2. WC 3. DATE

4. PART 1 - DISCREPANCY DESCRIPTION

5. ORIGINATOR SIGNATURE 6. QA SUPERVISOR SIGNATURE

QA RETAIN ORIGINAL AND FWD COPY TO DIVISION

7. PART 2 – CORRECTIVE ACTION
ROOT CAUSE:

CORRECTIVE ACTION:

8. ECD 9. DIVISION OFFICER (SIGNATURE) DATE

RETAIN COPY AND FWD COPY TO QA OFFICER

10. PART 3 - REINSPECTION/AUDIT COMMENTS

11. QA OFFICER/QA SUPERVISOR (QAO/QAS) (SIGNATURE) DATE

COPY TO: ORIGINAL - QA

DIVISION RECORD FILE