Management of Proposed Change Form

• Site conducted

  Select

• Conducted by

• Conducted on

  Date

Responsibilities

• Person Proposing Change

• Title

• Date

  Date

• Representative

• Title

• Date

  Date

• Reviewing Change

  Date

• Reason for Proposed Change

  Date

Affected Stakeholders e.g. Personnel Requiring Consultation:

• undefined

• Key Risks e.g. Potentially Associated with the Change

• Has a Risk Assessment been Completed<br>e.g. Attach copies of Risk Assessment, trials, consultation, etc:

  Yes

  No

  N/A

• If No or N/A comment below why not required.

Required Actions

• Training Required e.g. tom Implement Proposed Change:

• Proposed Monitoring e.g. Review Schedule to Ensure Safe Implementation:

• Other Changes Required e.g. Procedures, Documents, Duty Statements, Facilities to Accommodation

• Is this likely to require:<br>a) Additional or different license's for staff?

  Yes

  No

  N/A

• b) Notification to any government authority or council?

  Yes

  No

  N/A

• c) Any special requirements to ensure safety or compliance?

  Yes

  No

  N/A

• Planned Timing for Change

• Any Other Issues e.g. Concerning Proposed Change or Managing Change