Change Request Form

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Transcript of Change Request Form

Change Request Form

Change Request FormDocument of Record for a project change request

Project Name XXXXXXProject ID Number

Project SponsorProject Manager

Created byPerson submitting the change requestScope Change Number (must match Change Log entry)001

Date of RequestImplementation by:

Change Request Detail - The Change Request form is the document of record for a change request. It provides the business reasons and justification for the change and assesses the risk and impact of the change.

Type of ChangeDescription of the change requested with rationale

|_|Business Change or Need

|_|Funding Source Plan Change

|_|Scope Change or Need

|_|Schedule Change

|_|Error Correction

|_|Regulatory Requirement

|_|Other

Priority|_| 1 Critical: I cant move forward until this change is resolved.|_| 2 High: Im fine for right now, but unless this change is resolved by the due date, I wont be able to move forward.|_| 3 Normal: Im fine for the right now, but this may impact my ability to move forward in the near future.|_| 4 Low: This change is not impacting my ability to move forward.

Benefits of Proposed ChangedThe additional benefits the proposed change would have.

Alternatives List any alternatives/work-around to the change that exist.

Impact Severity|_| 1 - Critical Impact: Threatens the success of the program|_| 2 - High Impact: Significant disruption to program schedule, cost, or quality |_| 3 - Normal Impact: Progress disrupted with manageable extensions to short-term schedule and cost|_| 4 - Low Impact: Exposure is slight

List of Impacted Deliverables

Financial Impact ($)Estimated Cost of the Change

Schedule Impact (days)Time Required for the Change

Resources Required for Change

Impact Summary

Authorization

Who has the authority to approve this type of change?|_|Advisory Board|_|Business Office

|_|Steering Committee|_|Customer/Stakeholder

|_|Executive Sponsor|_|Other:

Change Requests Status|_|Change Request Open

|_|Change Request Approved

|_|Change Request Rejected

|_|Change Request Closed

|_|Deferred for review at later date Date:

Fiscal Reviewed and Approved byIf funding is sourced separately by a departmentDate:

Authorizing Signature Date:

Project Manager Signature Date:

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