Management of Change Form Template

• Site/Facility

• Conducted on

  Date

• Prepared by

• Location
  Address

Information

• Change Initiator

• Discription of proposed change

• Area of Change

• Proposed Date and Time to implement Change?

  Date

MOC Form

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is additional training on new procedures required before the change?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  No

  Yes

  N/A

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

  Yes

  No

  N/A

• Training and communications completed?

  No

  Yes

  N/A

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

  No

  Yes

  N/A

• Any other actions required as part of this change?

  Yes

  No

  N/A

• List the person/s responsible and due date

Completion of MOC

• Comments

• Operations/Facility: Name and signature

  Sign

• Building Facility: Name and signature

  Sign

• Area Supervisor: Name and signature

  Sign

• Bldg. or Utility Operations Engr: Name and signature

  Sign

• Safety Officer: Name and signature

  Sign