Title Page

  • Site/Facility

  • Conducted on

  • Prepared by

  • Location

Management of Change


  • Site

  • Change Initiator

  • Discription of proposed change

  • Area of Change

  • Areas/Departments effected by the change.

  • Proposed Date and Time to implement Change?


  • Will the change bring about alterations to the original design of 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, temperatures, lubrication, emissions, 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, flammable or combustible materials?

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

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

  • Will the change have an impact on the quality of maintenance? Completions of work orders and/or PMs.

Operating Personnel

  • Will the change require new personnel or the transfer of existing personnel?

  • Has a supervisor or manager's area of responsibility changed?

  • Do personnel require additional training to accommodate the change?

External Personnel on the site

  • Does the change require contractor personnel to be employed onsite?

  • Does the change require new contractors be employed onsite?

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

Regulations, Standards, or Code of Practice

  • Is the change as a result of a significant change in regulations, standard operating procedures, 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 significant alterations to the organisational structure?

Suppliers, Community and/or Client/User

  • Are there any added health, safety, and environmental risk to the suppliers, clients, users or the community?

  • Is there any added financial risk to the shareholders?

  • Are there any legal implications between the suppliers, clients, users and or community?


  • Will the change impact an existing environmental permit?

  • Will the change require a new or altered environmental permit?

  • Is there any added risk to the environment such as altering existing environmental status by generating any new or altered airborne emissions, liquid effluents, or solid debris, or affect the approved environmental management system?

  • Will the change impact existing JSAs?

  • Does the change require the development of new JSAs?

  • Will the change require new or additional PPE?

  • Is there any negative impact on fatality risks?


  • Is the change Permanent or Temporary?

  • Comments

  • Name and signature

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.