PRE-SHIPMENT ISSUE AND ACTION RECORD — BLANK WORKING TEMPLATE

Illustrative blank template only; not a completed customer, inspection or certification report. Complete your own copy outside this website.
This record documents an observed issue and its follow-up. It does not create an inspection scope, certify compliance or guarantee an entire production lot. The agreed inspection report and a separate decision by the authorized party remain necessary.

1. IDENTIFY THE GOODS AND CHECK
Product / model / specification version: ____________________
Order / shipment / lot reference: ____________________
Check location / date: ____________________
Person checking / role: ____________________
Approved specification / sample / checklist reference: ____________________
Agreed check method / scope / quantity sampled: ____________________
Lot quantity (state whether declared or observed): ____________________
Unchecked items / access or testing limits: ____________________

2. DESCRIBE ONE ISSUE
Repeat this block for each issue.
Issue ID: ____________________
Criterion / agreed acceptance limit: ____________________
Observed result / method: ____________________
Evidence photo / document ID / file location: ____________________
Deviation / severity under the agreed criteria: ____________________
Affected units observed / count / basis: ____________________
Uncertainty or items requiring separate testing: ____________________

3. AGREE THE ACTION
Correction / containment action: ____________________
Action owner / contact / role: ____________________
Agreed completion deadline: ____________________
Person who accepted the action / confirmation reference: ____________________

4. RECHECK AND RECORD THE AUTHORIZED DECISION
Recheck criteria / method / quantity / responsible person / date: ____________________
Updated evidence ID / recheck result: ____________________
Outstanding issues or conditions: ____________________
Shipment decision (pending / hold / conditional release / release): ____________________
Decision owner / authority / decision date / time zone: ____________________
Written authorization reference / accepted conditions: ____________________
Record revision / related inspection report: ____________________

A filled action record does not automatically release the shipment. Do not extrapolate observations to unchecked goods without a stated, agreed basis, or record an unresolved issue as passed.