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Management of Change

Information

Change Initiator

Discription of proposed change

Area of Change

Proposed Date and Time to implement Change?
MOC Form

Does the affected personnel (e.g. operations, maintenance, contractors, etc.) require notification or training associated with this change?

Are operating procedures or maintenance procedures required to be updated as a result of this change?

Is additional training on new procedures required before the change?

Does P&ID or other drawings require updating based on change?

Is the PHA, Offsite Consequence Analysis or Emergency Response Procedures impacted by this Change?

Does the Process Safety Information require updating as a result of this change?

If the change includes new equipment, has the Mechanical Integrity and testing inspection requirements updated accordingly

Other impacts to Covered Process? (if Yes, list on notes)

Training and communications completed?

Pre-Startup Safety Review (PSSR) completed with change?

Any other actions required as part of this change?

List the person/s responsible and due date

Completion of MOC

Comments

Operations/Facility: Name and signature
Building Facility: Name and signature
Area Supervisor: Name and signature
Bldg. or Utility Operations Engr: Name and signature
Safety Officer: Name and signature

Management of Change Form Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 41

A management of change form needs to be signed by all signatories to confirm approval of change/s being implemented. It also contains a list which confirms documentation of changes.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Management of Change

Information

Change Initiator

Discription of proposed change

Area of Change

Proposed Date and Time to implement Change?
MOC Form

Does the affected personnel (e.g. operations, maintenance, contractors, etc.) require notification or training associated with this change?

Are operating procedures or maintenance procedures required to be updated as a result of this change?

Is additional training on new procedures required before the change?

Does P&ID or other drawings require updating based on change?

Is the PHA, Offsite Consequence Analysis or Emergency Response Procedures impacted by this Change?

Does the Process Safety Information require updating as a result of this change?

If the change includes new equipment, has the Mechanical Integrity and testing inspection requirements updated accordingly

Other impacts to Covered Process? (if Yes, list on notes)

Training and communications completed?

Pre-Startup Safety Review (PSSR) completed with change?

Any other actions required as part of this change?

List the person/s responsible and due date

Completion of MOC

Comments

Operations/Facility: Name and signature
Building Facility: Name and signature
Area Supervisor: Name and signature
Bldg. or Utility Operations Engr: Name and signature
Safety Officer: Name and signature