-----------------------------------------------------------------------
  **This section to be completed by the Office of Quality and Best
  Practices**

  **IMS Item Tracking Number:**      

  **IMS Item Name:**      

  **Date Item Entered into IMS:**      

  **Division/Section:**      

  **Responsible Person:**      

  **Description of Activity:**      
  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| **This section to be completed by the Responsible Person**            |
+-----------------------------------------------------------------------+
| **Plan to meet activity requirements:**                               |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **Reporting Periodicity:**                                            |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **Link or source of information / objective evidence of compliance    |
| with activity requirements:**                                         |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **Planned start and stop dates:**                                     |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **Point of Contact if not Responsible Person:**                       |
|                                                                       |
| **Name:      **                                                       |
|                                                                       |
| **Phone #:** 000-000-0000                                             |
|                                                                       |
| **Email:      **                                                      |
+-----------------------------------------------------------------------+
| **Comments:**                                                         |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+

Table of Revisions

  ------------------ --------------------------------- ---------- ----------
  Author             Description                       Revision   Date

  Nathan Weed        Draft based on IMS Corrective and 001        11/20/07
                     Preventive Action Plan Form                  

                                                                  

                                                                  

                                                                  

                                                                  

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