My experience has taught me to keep these type of forms as simple as possible.
1) Identify the material. Lot/batch/serial numbers. Quantity with/without defect. Exactly where in-process is the material, physically, inventory-tracking, process step.
2) Specifically what is the nonconformance/defect.
3) What needs to be know to make a disposition?
4) Approval for the disposition.
5) Information you want to trend. Defect, Root cause, etc.
I hope this helps,
KenQE