the format seems to be accurate, but I would like to give you some inputs if accepted.
I do not see a reference to the rework instructions to be followed.
Then , who will approve if the rework went well ? In other terms, I do not see the clear responsibility ( QA mgr?) and the reference to the requirements of the re-control.
How will the reworked product be traced and identified?
How many reworks could be acceptable for your product?
These are some ideas of mine to improve the form.
I also suggest to have a procedure for this process and train the personnel on this item.
Which kind of certification do you have? Which business and product do you operate?
Hope these suggestion could be appreciated...