SAMPLE APPROVAL RECORD — BLANK WORKING TEMPLATE

Illustrative blank template only; not a completed customer, inspection or certification report. Complete your own copy outside this website.
A sample decision applies only to the identified sample, specification version and agreed criteria. It is not a compliance certificate, shipment release or guarantee for an entire production lot. Identify any required testing or certification separately.

1. IDENTIFY THE SAMPLE AND REFERENCE
Product / model: ____________________
Product specification version / date: ____________________
Sample ID / label / quantity: ____________________
Sample received date: ____________________
Reference drawing / photo / agreed requirement IDs: ____________________
Person checking / role / check date: ____________________

2. RECORD EACH CRITERION AND OBSERVATION
Repeat this block for each agreed criterion. Leave untested criteria explicitly untested.
Criterion / agreed acceptance limit: ____________________
Observed measurement or result / method: ____________________
Evidence photo / document ID / file location: ____________________
Deviation from the agreed requirement: ____________________
Criteria not checked / limits of the check: ____________________

3. RECORD THE DECISION
Decision (pending / approved / approved with listed conditions / rejected): ____________________
Approved version / intended use / limitations: ____________________
Conditions or corrections required before production use: ____________________
Decision owner / authorized role: ____________________
Decision date / time zone: ____________________
How the decision was confirmed in writing: ____________________

4. CORRECT AND RECHECK
Action required / action owner: ____________________
Agreed completion deadline: ____________________
Recheck criteria / method / responsible person / date: ____________________
Updated evidence ID / recheck result: ____________________
Final decision owner / decision / date: ____________________
Record revision / related records: ____________________

Keep this sample record separate from any inspection report, required test result and shipment decision. Do not replace an untested item with an assumed pass.