MATERIAL/PROCESS DEVIATION AUTHORIZATION / Log No:
Part Number: / Rev: / Part Name: / Requested Date:
Requester: / Supplier: / PO/SO No.:
Limitations (Qty, Serial # or Date): / Unit Model:
Cost of Scrapped Parts: / Lead Time of Replacement Parts:

(Not to exceed 120 days)

Department requesting the Change Request
Engineering / Supply Management / Manufacturing / Other
Plants Affected
Arecibo / Galway / Langeskov / Service Parts / Hastings
Barcelona / Gunma / Londrina / Shenzhen / Unicov
Ciales / Kolin / Louisville / Suzhou
REASON FOR DEVIATION (Business Need)

SAFETY ISSUE

/ QUALITY ISSUE / PLANT SHUT DOWN ISSUE / MDA EXTENSION
Detail:
Impact on Unit Quality: (Check those Applicable)

Appearance

/

Reliability

/

Function

/
Ship Units Less Parts / Cost / Performance / None - (No Effect)
Detail:
MDA Risks (Customer or Plant):
Detail: / None
Material/Process Modifications Required to Use Part
Detail: / None
Material Deviation Authorization Page 2 Log No.
ROOT CAUSE AND PERMANENT CORRECTIVE ACTION (Completed by the Functional Manager of the department requesting the change)
Detail (Additional details on root cause of this MDA):

Is field service/follow-up required? Yes No

/ / Is Windchill change required? Yes No
MRN # / CAP Report # / Windchill change request#
Approval from Originator’s Direct Supervisor or Direct Supervisor’s SupervisorA plan has been developed and I will actively manage the plan to ensure that the above windchill will be released prior to the 120-day expiration of this MDA.
I have carefully reviewed this MDA and agree that this MDA meets the Q&R guidelines. I assume all responsibilities for issues resulting from approval of this MDA. .
Supervisor’s Signature: / Supervisor’s Name:
(This Authorization is NOT valid until ALL MANDATORY signatures are obtained)
Mandatory Signatures: / Other Required Signatures: (Indicate with an ‘X’)
Date / Date
Design Engineering (Product Engr): / Customer Service/Sales Mgr:
Plant Quality Assurance Mgr: / Service Mgr:
Operational Excellence: / Purch/Supply Mgr:
Plant Mat’l / Prod Plng Mgr: / Product Market Mgmt:
Plant Mfg. Engineering: / Other:
Non-Approval Signature and Comment
Name: / Comment: / Date:
It is the requesters responsibility to return a copy of this non-approval to all above signee’s.
120 day Extension: Additional Required Signatures:
Required Signatures Date
NAD Required Signatures (plants affected)
Plant Manager
ESA Required Signatures (plants affected)
Plant Manager
Asia Pacific Required Signatures (plants affected)
Plant Manager
Additional Global Signatures (plants affected)
Global VP Operations
Global V.P. Engineering

TK 1654-A (6/95) 710F00-002E

Modified 10/27/04