MARITIME CLINIC FOR INTERNATIONAL SEAFARERS, INC.

CORRECTIVE ACTION REQUEST FORM CAR NO. 016

Internal Audit  Day to Day Operational Process Output

INTERNAL Customer Complaint Risk/KPI/Quality Objective

Material/Document Verification Others _________________

ISO 9001 Audit REGULATORY BODY AUDIT

EXTERNAL Manning Agency DOH DOLE
Others: ________________ MARINA DENR

PART 1: TO BE FILLED OUT BY QUALITY MANAGER

FINDING:  NONCONFORMITY OPPORTUNITY FOR IMPROVEMENT (OFI)

Nonconformity Description:

Printed medical certificates for Mr. Jopillo, Francis David of MagMOL is his previous medical dated
1/16/2018 and not the latest PEME dated 12/11/2018 and included for delivery today.

Evidence of Nonconformity: Printed medical certificates and the Transmittal .

IS THERE AN IDENTIFIED RISK?  YES NO

IF YES, STATE THE RISK: Possible complaint from Manning Agency

RISK ASSESSMENT:  HIGH (Requires Mitigation Measure) LOW (Acceptable Risk)

Prepared by: Connie M. Anim (QUALITY MANAGER) Date: 12 December 2018

Approved by: Dr. Cristina Chua-Camacho (DEPARTMENT HEAD) Date: 12 December 2018

IF THIS NONCONFORMITY IS CAUSED BY SUPPLIER/SERVICE PROVIDER, SCAN AND E-MAIL THIS TO

RESPECTIVE SUPPLIER/SERVICE PROVIDER, cc: THE FINANCE MANAGER, THE QUALITY MANAGER
AND THE MEDICAL DIRECTOR

PART 2: TO BE FILLED OUT BY RECIPIENT OF CAR

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IMMEDIATE COUNTER MEASURE:
Doctor’s Patient List page counter checked with Saemed PEME Record

Responsible: _Shalinur Hussein Gonzales___Implementation Date: ___December 14, 2018______________

CAUSE ANALYSIS: PLEASE ATTACH ANY ADDITIONAL INVESTIGATION DETAILS:

I only verified the medical records under Dra. Chua’s name and used it as reference because it states
2018. I failed to counter check with Saemed PEME Record that states that the patient has undergone a
new medical examination under Dr. Piano

PROPOSED CORRECTIVE ACTION / PLANNED ACTION TO MITIGATE RISK:

Counter checked with Saemed PEME Record always. To enhance the Saemed Search Engine. Include
fitness or completion date in order to avoid previous peme of crew.

Implementation Date: __December 14, 2018____ ___ ___

Noted by: __Thelma C. Cayabyab__ (Department Head) / Supplier/ Service Provider

Date: __December 14, 2018____ ___ ___

IF THIS CAR IS CAUSED BY SUPPLIER/SERVICE PROVIDER, SCAN AND E-MAIL THIS TO PURCHASING
OFFICER OF MCIS, cc: THE FINANCE MANAGER, QUALITY MANAGER & THE MEDICAL DIRECTOR

PART 3: VERIFICATION RESULT

VERIFICATION DETAILS:

Verified by: ________________________ (QUALITY MANAGER) Date: _________________

Is the verified corrective action implemented and effective?

IMPLEMENTATION: IMPLEMENTED NOT IMPLEMENTED

EFFECTIVENESS: EFFECTIVE NOT EFFECTIVE

CAR STATUS: OPEN CLOSE

REMARKS: ________________________________________________________________________

Reviewed by: _______________________ (QUALITY MANAGER) Date: _________________

Approved by: _______________________ (MEDICAL DIRECTOR) Date: _________________

QMS-RF-005, Page 2 of 2
REV. 0, 01 SEPT 2017