Title Page

  • Change Request No.

  • Contract No.

  • Type of Change Request

  • Project Name

  • Change Requested by

  • Date Submitted

  • Date Required

  • [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

  • Brief description of request (Enter detailed description of the change being requested)

  • Priority level

  • Reason for change

  • Take photo evidence of item/areas affected and needed to modify

  • Assumptions and notes regarding the requested change

  • Name & Signature of Submitter

PROJECT MANAGER - Initial Analysis

  • Hour impact

  • Duration impact

  • Schedule impact

  • Attachments or references (i.e ., photos of drawings, specifications, schedule etc)

  • List down estimated cost of labor and the necessary materials needed

  • Name & Signature of Project Manager


  • Decision

  • Specify Conditions

  • Decision Date & Time

  • Approval Signature

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