Вы находитесь на странице: 1из 6

Quality Assurance De

Quality Problems Report
Occurence Date

Control No.
Step Step 1 Step 2 Step 3 Step 4
Why did the problem occur ?
Why -Analysis
for recurrence
Why pass from your inspection ?

1. Phenomenon Site, number of units, condition (s) SAFETY 3. Countermeasure / Action Tentative and fibal countermeasures / number of units affected 5W1
YES NO Action for units in the market, warehouse and factory
Cause of category :
Process :

Part :

Design :

Calibration F :

Aproved Issued

Response due date : Effective date of countermeasure : PIC :

2. Cause 4. Recurrence Prevention 5W1


Effective date of countermeasure : PIC :

Work Process Confirm Improvement 1st

Dept Work Direction Check Sheet PFMEA
Flow: Instruction Control Chart Effectiveness Lot Confirmation
Revision OK NG OK NG
Problem found -> Fill in available information for quick information sharing -> Problem Solved -> Submit to QA by request from QA-TL -> of Documents

-> Approved, registered and distributed by AQ/Confirm effectiveness by QA or QA

Date : Date :
Quality Assurance Dept.

Approved Verified

Step 5

5W1H must be described

5W1H must be described


Approved Verified
Date : Date :

Approved by QA Dept
Fill in by issuer/internal dept/ sub-contract

Doc No. : ........................

Model No. : ........................
Name of Dept/ Vendor/ Sub Contract
Approved Veified Reported
Date : Date : Date :
Date of Change (Plan)

Reason of change :

4M Variation Category

Man Material

Machine Method

Content of change : Attached document with this 4M :

Fill in by QA/QC and Engineering Dept

Criteria Judgement (* Please circle option)

Dimension OK NG Appearance OK NG Reliability OK NG OK NG


Accept Reject

Need Test Run

Approved Veified Evaluated
Need Test Run No Need
Date : Date : Date :
Need PHC Approval
Need No Need

4M CHANGE APPROVAL (Note : GM Approval is necessary if change not submiting for PHC/Customer approval)

GM PHC Comments
Date : Date : Sign/ Stamp :
Distribution :
PT PHC Indonesia Page :
Kawasan Industri MM2100 Blok O-1 Cikarang Barat Date :
Bekasi 17520, INDONESIA Revise :
Tel : 62-21-898-0005 / Fax : 62-21-898-1485 Doc. No :

To : Charge To :
Company : Company :

Attn. : Attn. :
Cc : Cc :
Address : Address :

Division Code :

Dear Sir / Madam,

We would like to charge you the cost with below details :



( For detail cost please see attachment ) * ( USD, IDR, JPY )

Please sign in Approval bos for your acceptance and return back to PT PHC Indonesia by email or
Fax No : +62 21 8981485. For further queries and information, please feel free to contact us.


Thank you for attention and cooperation.
I hereby confirmed and Approved for
Departement : all content in Billing Confirmation

Approved Reviewed Prepared Approved

Date : Date : Date : Date :

( Sign, Name and Company Chop )

Internal memo : We will pay on :
To Accounting Dept. : Please issue DEBIT NOTE for this Billing Confirmation
Control List of Change Point

1 Part Name :
2 Part Number :
3 Company Name :
Please fill the following items for its change

2018 April July October January

1 Date of Confirmation October
2019 April July October January
Change item :
Chairman of Quality
2 Not Change Change
Assurance Compliance
Change item :
3 Design Not Change Change

Change item :
4 Material Not Change Change

Change item :
5 Dies Not Change Change

Change item :
6 Equipment/Jig/Tooling Not Change Change

Change item :
7 Production Place Not Change Change

Change item :
8 Production System Not Change Change

Change item :
9 Inspection System Not Change Change

Remark/Comment :

Note : Please report this from every 3 month on the 5th of April, July, October and January.