Template

RCA Evidence Collection & Verification Template

An interactive evidence-capture and verification package for root cause facilitation. Collect timelines, attachments, witness statements, tests/reproductions, hypotheses with supporting evidence, countermeasure plans, and a verification checklist that records acceptance criteria and closure readiness.

Interactive Tool

RCA Evidence Collection & Verification

Use this form during or immediately after an RCA facilitation session to capture the evidence package required for verifiable closure. Complete the timeline, attach or link supporting artifacts, record witness summaries, document test steps, map hypotheses to supporting evidence, define countermeasures with owners and due dates, and run the verification checklist against explicit acceptance criteria.

Guidance: Be concrete. Prefer links to original artifacts (photo filenames, log names, spreadsheet URLs, piece of equipment IDs) over summary sentences. Where reproduction or test steps are used, include expected vs observed results. When in doubt, capture more evidence details — weak evidence is the common reason RCAs reopen.

Unique identifier (e.g., CAR-2026-045 or Incident #).
Person running the RCA session.
YYYY-MM-DD or natural language date.
Brief, time-ordered bullets showing critical events, handoffs, and timestamps where possible. Start with the earliest observable event relevant to the incident.
List filenames, URLs, system log references, photo IDs, video clips, or location of physical artifacts. If items exist in your Deck or repository, paste links or stable identifiers.
Note the exact file or log lines that support timelines or hypotheses. Prefer direct links where available.
For each witness, record name, role, short summary of observed facts, and whether a full signed statement is stored elsewhere.
List steps to reproduce the issue or the test performed, expected result, observed result, tester name, and date/time.
Summarize relevant metrics, baselines, calculations, and time windows. Reference original datasets or dashboards.
State the hypothesis clearly (cause-effect link).
Cite the specific artifacts, observations, tests, or measurements that support this hypothesis.
Optional. Capture alternative hypotheses to be tested.
Describe supporting or contradicting evidence.
Optional third hypothesis.
Describe supporting or contradicting evidence.
Choose the hypothesis selected for countermeasure development or choose Other.
Explain why the selected cause is supported by the evidence and why alternatives were rejected. Be specific about which artifacts support which claim.
Describe each countermeasure, expected effect, scope (temporary/permanent), and implementation steps. For multiple actions, list as Action / Owner / Due date / Success metric.
Person accountable for ensuring the countermeasure is implemented.
YYYY-MM-DD or descriptive timeframe.
How will you measure effectiveness? Include metrics, sampling plan, frequency, and who reviews results.
Answer Yes only if specific artifacts validate the causal link and alternatives are plausibly excluded.
If partially implemented, explain status in Verification Notes.
Concisely state the measurable acceptance criteria used to judge effectiveness (e.g., defect rate from X to Y within Z days).
Dates or duration over which the acceptance criteria will be observed.
Summarize measurement results and link to monitoring artifacts. Note any residual risk or need to scale actions.
Rate how confident the team is that the evidence supports the root cause selection.
1.0 10.0
Indicate whether artifacts referenced here are stored where reviewers can find them.
Select whether the package is ready to close the RCA or needs further work.
If ready, the date when closure will be recorded.
Person who will sign off on closure.
If yes, specify owner and due date in the fields below.
Person responsible for post-closure monitoring or sustainment.
YYYY-MM-DD or relative timeframe.
Any closing notes, risks, or recommendations for future reviews.
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