Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

General info

  • Change Initiator

  • Discription of proposed change

  • Area of Change

  • Proposed Date and time to implement Change?

  • Any Change Management must be submitted to the General Manager for approval 48 hrs , prior to the intended change being implemented.


Engineering/Mining Processes

  • Will the change bring about alterations to the origanal design of the machine/equipment?

  • Will the change bring about a change to maintenance, equipment operating methods or safety devices?

  • Will the change result in a negative impact on pressures , tempretures, lubrication, emmisions, vibration or ergonomics?

  • Will the change initiate any new construction , modification of existing facilities, or decommissioning activities?

  • Will the change requie or involve any excavation, soil contamination or contamination of ground water?

  • Will the change involve, result in or generate radioactive,hazardous or mixed waste such as any new or altered carcinogenic, corrosive, biological ,radioactive, or infectious chemical or agents?

  • Will the change requier the use of large quantities of flammable liquids?

  • Will the change require that combustable liquids are heated above or close to their flashpoints?

  • Does the change require the use of storage tanks or the storage of large quantities of hazardous , radioactive, flammable or combustible materials?

  • Does the change involve any High -energy sources( e.g. Radiation, electromagnetic, laser, compressed gasses, propellants and/or explosives?

  • Will the change alter any pre -start inspection schedule?

  • Does the change alter the validity of of any certification, exemptions, or permissions?

Operating and Design

  • Will the change alter existing hardware and/or control software?

  • Will this alter emergency response used on site?


  • Will the change have an impact on the quality of the product or service?

  • Will the change have an impact on the quality of maintenance?

Operating Personnel

  • Have personnel changed?

  • Has a person's area of responsibility changed?

  • Do people require additional training to accomodate the change?

External Personnel on the site

  • Does the change require additional contractor personnel to be employed outside the current contract?

  • Will the change require a change in scope of work conducted by contractor personnel?

  • Will the change require a change in contractor company performing the work?

Regulations, Standards or COP's

  • Is the change as a result of a significant change in regulations, standards or any Code of Practice?

  • Is the change as a result of a CLIENt requirement, standard?<br>

  • Is there a change required to procedures and/or training material?

  • Not covered in procedures or Code of Practices?

Organisational Structures

  • Will the change require significantalterations to the organisational structure?

Suppliers, Community and/or Client/User

  • Are ther any added HSEC risk to the suppliers, clients, users or the community?

  • Is there any added financial risk to the shareholders?

  • Is there any legal implecations between the mine and suppliers, clients, users and or community?

  • Will the change need approval from the OEM?


  • Is there any added risk to personnel with regards to Health & Safety (Hierarchy of control)

  • Is there any added risk to enviroment such as altering existing enviromental status by generating any new or altered airborne emmisions, liquid effluents, or solid debris, or affect the approved EMP?

  • Will the change require new or additional PPE?

  • Is there any negative impact on any of the Fatal Risks?<br>

Final Analysis

  • Is the change Permanent or Temporary

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.