Event Tracking Number: ________
Time : ______
Root Cause Analysis Template 1 of 2
Sample Form for Performing a Simple Root Cause Analysis
Case Information
Person’s last name, first name: ___________________________________
Person’s date of birth (mm/dd/yyyy): __ __ / __ __ / __ __ __ __
Person’s gender: Female Male
Participants in the Root Cause Analysis (Indicate name and position)
____________________________________________ (Lead)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Root Cause Identification
In each of the areas below, indicate any factors that contributed to the delay in treatment: