Non-Compliance Form Check List
Use this form to complete and review Non-Compliance forms
Header:
Yes
Is the date filled in?
Is the Project Administrators name in the “from” line?
Is Financial Project number filled in?
Is Federal Contract number filled in?
Is Contract number filled in?
Is the specification year/section filled in and correct?
Is the State Road Number filled in?
Is the County filled in?
Table:
Are the following correct:
 Material ID.
 Sample Level.
 FDOT sample ID and LIMS/MAC number?
 Date Test Performed:
 Location?
o Does the location provide station to and from?
 Quantity?
o Do the stations calculate correctly?
o Do they exceed the maximum allowed?
 Reason for the Non-compliance:
Does the recommendation make sense?
Does the Justification have supporting documentation and align with the
recommendation?
Do the preventive measures seem clearly defined and attainable?
Materials will add their comments if needed, making sure they are clear and
concise.
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No N/A
Additional information:
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