Title Page
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Change Request No.
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Contract No.
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Type of Change Request
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Project Name
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Change Requested by
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Date Submitted
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Date Required
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[This form is divided into three sections. Section 1 is intended for use by the individual submitting the change request. Section 2 is intended for use by the Project Manager to document/communicate their initial impact analysis of the requested change. Section 3 is intended for use by the Change Control Board (CCB) to document their final decision regarding the requested change.]
SUBMITTER - General Information
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Brief description of request (Enter detailed description of the change being requested)
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Priority level
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Reason for change
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Take photo evidence of item/areas affected and needed to modify
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Assumptions and notes regarding the requested change
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Name & Signature of Submitter
PROJECT MANAGER - Initial Analysis
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Hour impact
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Duration impact
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Schedule impact
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Attachments or references (i.e ., photos of drawings, specifications, schedule etc)
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List down estimated cost of labor and the necessary materials needed
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Name & Signature of Project Manager
CHANGE CONTROL BOARD - Decision
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Decision
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Specify Conditions
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Decision Date & Time
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Approval Signature
