Root Cause Report Form

ROOT CAUSE ANALYSIS REPORT FORM1 AGENCY: Reference No.: Program/Facility: Region STS North South West Consumer ID: Age: Gender: M F MR Level: NR ML MO SV PR City/Town: Date of Event: Date RCA Completed: 1.. 2.19 What other factors are considered relevant to the adverse event Describe: 2.20 Rank order the factors considered responsible for the adverse event, beginning with the proximate cause, followed by the most important to less important contributory factors.. Rank Strategy Estimated Cost Special Considerations 1 2 3 4 5 6 7 5 INCIDENTAL FINDINGS List and describe any incidental findings that should be carefully reviewed for corrective action..