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  **NSLS FAMILY ATS ENTRY REQUEST FORM**

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> **\*Required Information**

Please complete this form and forward to the [NSLS ATS
Administrator](mailto:wrigley@bnl.gov) for entry into the NSLS Family
Assessment Tracking System. Please include any files that need to be
attached to the ATS assessment, condition, or action.

+-----------------------+----------------------------------------------+
| **[Assessment         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| **(100 Characters     |                                              |
| Max):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Assessment         | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Assessment         | **     **                                    |
| Delegate**            |                                              |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Planned Assessment | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **[Date Assessment    | **     **                                    |
| St                    |                                              |
| arted]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| **[Assessment         | **     **                                    |
| Completion            |                                              |
| D                     |                                              |
| ate\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+

[**Assessment Type\*** (select one)**:**]{.underline}

  ----------------------------------- -----------------------------------
  **Committee Commitments**           **Occurrence Report (ORPS)**

  **Conduct of Ops**                  **OHSAS Assessment/Audit**

  **EMS Assessment**                  **Other**

  **External**                        **PAAA Issue**

  **Internal Audit**                  **Records Management**

  **Internal Self-Assessment**        **Regulatory Issue**

  **Maintenance**                     **Suggestion/Feedback**

  **Metrology Issue**                 **Tier I Inspection**

  **Nonconformance Report (NCR)**     **Work Planning Assessments**
  ----------------------------------- -----------------------------------

**[Assessment Description]{.underline}**\*: (Include brief description,
usually summary or assessment results from report)

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

+-----------------------+----------------------------------------------+
| **[Condition #1       | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| **(100 Characters     |                                              |
| Max):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Condition          | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Condition          | **     **                                    |
| Delegate**            |                                              |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Condition Due      | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+

**[Condition Type\* (select one):]{.underline}**

  ----------------------------------- -----------------------------------
  **Action Plan**                     **Notification**

  **Awareness**                       **Observation**

  **Finding**                         **Opportunity for Improvement**

  **Major Nonconformance (ISO         **Other**
  14001)**                            

  **Milestone**                       **Out of Specification**

  **Minor Nonconformance (ISO         **Recommendation**
  14001)**                            

  **Non-Compliance**                  **Unreviewed Safety Determination**

  **Nonconformance**                  **Violation**
  ----------------------------------- -----------------------------------

**[Condition Description]{.underline}**\*: Choose default statement or
enter other statement below:

Default Condition Description Statement:

\"The actions associated with this condition address the findings of the
assessment and are included in the Corrective Action Plan of the
report\".

**[OR]{.underline}**

**Other:** (Include brief description of causes, usually analysis or
assessment results from report)

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

+-----------------------+----------------------------------------------+
| **[Action #1          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #2          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #3          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #4          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #5          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #6          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #7          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #8          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #9          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #10         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #11         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #12         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Condition #2       | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| **(100 Characters     |                                              |
| Max):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Condition          | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Condition          | **     **                                    |
| Delegate**            |                                              |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Condition Due      | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+

**[Condition Type\* (select one)]{.underline}**:

  ----------------------------------- -----------------------------------
  **Action Plan**                     **Notification**

  **Awareness**                       **Observation**

  **Finding**                         **Opportunity for Improvement**

  **Major Nonconformance (ISO         **Other**
  14001)**                            

  **Milestone**                       **Out of Specification**

  **Minor Nonconformance (ISO         **Recommendation**
  14001)**                            

  **Non-Compliance**                  **Unreviewed Safety Determination**

  **Nonconformance**                  **Violation**

  **Action Plan**                     **Notification**
  ----------------------------------- -----------------------------------

**[Condition Description]{.underline}**\*: Choose default statement or
enter other statement below:

Default Condition Description Statement:

\"The actions associated with this condition address the findings of the
assessment and are included in the Corrective Action Plan of the
report\".

**[OR]{.underline}**

**Other:** (Include brief description of causes, usually analysis or
assessment results from report)

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

+-----------------------+----------------------------------------------+
| **[Action #1          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #2          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #3          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #4          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #5          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #6          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #7          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #8          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #9          | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #10         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #11         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+

+-----------------------+----------------------------------------------+
| **[Action #12         | **     **                                    |
| T                     |                                              |
| itle\*]{.underline}** |                                              |
|                       |                                              |
| (100 Characters Max): |                                              |
+-----------------------+----------------------------------------------+
| **Priority\* (select  |                                              |
| one):**               |                                              |
+-----------------------+----------------------------------------------+
| **[Action             | **     **                                    |
| Ow                    |                                              |
| ner\*]{.underline}:** |                                              |
+-----------------------+----------------------------------------------+
| [**Action Delegate**  | **     **                                    |
| (Option               |                                              |
| al)]{.underline}**:** |                                              |
+-----------------------+----------------------------------------------+
| **[Action Closure Due | **     **                                    |
| D                     |                                              |
| ate\*:]{.underline}** |                                              |
+-----------------------+----------------------------------------------+
| **Action Closed       | **     **                                    |
| Date:**               |                                              |
+-----------------------+----------------------------------------------+
| **Action              | **     **                                    |
| Description\***:      |                                              |
+-----------------------+----------------------------------------------+
| **History** (if       | **     **                                    |
| applicable):          |                                              |
+-----------------------+----------------------------------------------+
| **Distribution:**     | **     **                                    |
+-----------------------+----------------------------------------------+