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NCR # '~ ~ ~~ 7 ~ CONTROLLED Paragon flnalytics <br />~p NON-CONFORMANCE REPORT <br />Initiated by i! I Date ~~ Method/Procedure ~ ~ ~ ~ 1 t(, O. ~ <br />Reason: '' 1VOn-Conformance Work Orders Affected py- 070 3'~ <br />Client Inquiry <br />Other Clients ~'ttn.~C, <br />SECTION I TYPE OF EVENT (circle as appropriate) Explanation: 5' ~e s f P 1 UPr) n~~ <br />_ 1. LCS /Surrogate / IS /Tracer or Chemical Yield ln~lcl~~e }twerp {,,.1" ~ {~- ~~ "(-DS <br />Criteria Not Met <br />_ 2. Calibration Criteria Not Met (ICAL, ICV, CCV ) <br />3. Method Requirements Not Met (~MB, ) <br />4. Deviation from LQAP /SOP (i.e., PAI criteria not met) <br />_ 5. Client Criteria Not Met (MDC, DER, ) <br />_ 6. Eqtripment Failure or Laboratory Incident /Error <br />7. Other <br />SECTION IV REQUEST FOR REWORK <br />Initial Batch ID: <br />Reworked Batch ID: Date: <br />Outcome: _ I _tl <br />Actions to Prevent Recurrence (Retrain, etc.): N {~ '~ ~C ~/e~/ ~y Gs <<"+ y~'"'~ <br />SECTION II NOTIFICATION <br />p~t~;, ~ ~a =t- <br />p <br />Client Contacted? (~Y ! N) Name: ~. (~c~~ Date: Tune: <br /> <br />SECTION III CORRECTIVE ACTIONS <br />- 1. Submit for Re-Prep. or Clean-up <br />2. Re-analyze <br />_ 3. esubmit Data ( hc, edd, narrative ) <br />_ 4~. Document in Narrative <br />5. Other <br />Approved by: DPM PM <br />A ved by: <br />Matrix Effect or Elevated /Sample Activity Suspected? (ctrcle applicable) <br />~ SECTION V DISPOSITION .[Use as is / Repair Reject ~ <br />SECTION VI COMMENTS ~.,,..e ` <br />d <br />SECTION VII APPRO A <br />Project Manager (PM) Date ~ b G <br />Department Manager M) Date 7 ~ 6 (Verification of Disposition) <br />QA Managet - ~ ~ Date 7 f a y <br />SECTION VIII DISTRIBUTION Af PM Ey~~-Dept. Manager .Lab Duector ~ Rpt.Group or , Rad <br />FORM 313r14.doc (3/8/04) <br />~~~ ~1 <br />