Change Request Form

Service Name Requested From: Raised By: Phone/Division/ Organization

Change Number Date of RFC Raised Date Decision Change is Required By Date Deployment Completion is Required By

Change Name


Approved Rejected Deferred


Description of Change:

Business requirements refer to associated BR document Reason for Change: Justification Corrective Preventive Adaptive Perfective Configure Install Move Change

Priority Assigned


Date Change Assessed Date Change Initiator Informed

If Rejected or Deferred: Reasons for Rejection or Deferral

Impact of Change to the Business (H/M/L) How it is affected the business of PG/Company Review the required change and its impacts

Urgency (H/M/L) How quickly required to be implemented Review the required change and its impacts

Impact of the change on Users/Departments Define the related risks and consequences

Documents and Contracts

Other Services


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Change Request Form

CAB Comments/Issues/Decisions Define the related risks and consequences Provide the needed actions to avoid/reduce the risks

Date CAB meeting Held

Estimated effort Proposed Start Date time of Implementation Change Authorization By Name Application Manager CAB Members

Date Change Authorized Proposed End Date time of Implementation Approved Signature Rejected Deferred Date

Problem and Solution Description (Action Items)

Date Change Built/Acquired Actually Completed Date Deployment Actually Applied Testing Plan Implemented? Knowledge Transfer Required? Yes Yes No No

Date of Change Communication Date Change Check Completed Back out Implemented? Knowledge Transfer implemented? Yes Yes No No

Date Deployment Scheduled Change Checked By Date Back out Completed Date Knowledge Transfer started and ended

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