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NCR # ~~,~ <br />Initiated by ~ Date <br />Reason: ~1SIon-Conformance <br />Client Inquiry <br />Other <br />CONTROLLED Paragon Analytics <br />NON-CONFORMANCE REPORT <br />3 / ~ Method/Procedure <br />Work Orders Affected D 7 6 3 2~ g <br />Batches Affected (optional) <br />Clients ~'~ rf/(L ~ <br />SECTION I TYPE OF EVENT (circle as appropriate) <br />I. LCS /Surrogate / IS /Tracer or Chemical Yield <br />Criteria Not Met <br />_ Z. Calibration Criteria Not Met (ICAL ICV, CCV ) <br />_~. Method Requirements Not Me (HTV MB, _ ) <br />_ 4. Deviation from LQAP/SOP (i.e., PAR criteria not met) <br />_ 5. Client Criteria Not Met (MDC, DER, ) <br />_ 6. Equipment Failure or Laboratory Incident /Error <br />7. Other <br />Explanation: dd 5. <br />/ ~// 9; <br />~a ~„ ~ rn ~rc~e, <br />Actions to Prevent Recurrence (Retrain, etc.): CCd~~~ uA~ <br />SECTION II NOTIFICATION <br />Client Contacted? (Y / ~ Name: Date: Time: <br />SECTION III CORRECTIVE ACTIONS <br />1. Submit for Re-Prep. or Clean-up <br />2. Re-analyze <br />3. Resubmit Data ( hc, edd, narrative ) <br />r/v. Document in Narrative <br />5. Other <br />Approved by: DPM <br />SECTION IV REQUEST FOR REWORK <br />Initial Batch ID: Date: <br />Reworked Batch ID: <br />Outcome: <br />or Elevated /Sample Activity Suspected? (circle applicable) <br />SECTION V DISPOSITION Use Repair Reject <br />SECTION VI COMMENTS <br />SECTION VII APPROVAL SIGN S - <br />Project Manager (PM) ~ Date S 3/ <br />Department Manager ( - - ~- Date g ~t S/ p+}- (Verification of Disposition) <br />QA Manager Date ! ~ <br />SECTION « DISTRIBUTION ~ PM Dept. Manager Klt~,ab Duector /RptGroup or _ Rad <br />FORM 313 r15.doc (7/18!04) <br />9 <br />