PROJECT CHANGE REQUEST FORM

Project Name:

Prepared by:

Date (MM/DD/YYYY):

Control No. (from CR Log):

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Refer to the Change Management Plan for instructions on how to use this document.
1. Requestor Information
Fill in with appropriate information or place an “X” next to those that apply:
Area of Change:
Scope
[ ]

Schedule
[ ]
Budget
[ ]

Quality
[ ]
Is this Change the result of a Risk Management Action?
No
[ ]
Yes
[ ]
Risk ID:

Proposed Change Description and References:
Provide information below concerning the requested change. Create links to any supporting documentation.
Description:

Justification:

Hyperlinks:
Link_To_Supporting_Document1
Link_To_Supporting_Document2
Impact of Not Implementing Proposed Change:

Alternatives:


2. Initial Review Results of the Change Request
Initial Review Date: (MM/DD/YYYY)

Assigned to:

Action

Comments
Approve for Impact Analysis
[ ]

Reject
[ ]

Defer Until (MM/DD/YYYY)
[ ]

Express Approval
[ ]

3. Initial Impact Analysis
Baselines Affected:

Configuration Items Affected (e.g. product specifications):

Cost / Schedule Impact Analysis Required? (check one)
Yes [ ]
No [ ]
Impact on Cost:

Impact on Schedule:

Impact on Resources:

Risk associated with implementing the change:

Risk associated with not implementing the change:

Final Review Results:

Review Date: (MM/DD/YYYY)

Priority: (check one)
High [ ]
Medium [ ]
Low [ ]


4. Impact Analysis Results
Specific Requirements Definition:

Additional Resource Requirements (insert rows as needed):
Work Days
Cost









Totals



Impact of Not Implementing the Change:

Alternatives to the Proposed Change:


5. Final Recommendation


6. Project Change Request Form / Signatures
Project Name:

Project Manager:

I have reviewed the information contained in this Project Change Request Form and agree:
Name
Title
Signature
Date

(MM/DD/YYYY)

























The signatures above indicate an understanding of the purpose and content of this document by those signing it. By signing this document, they agree to this as the formal Project Change Request Form.