Change Request

Project Name

Project Reference Number

Prepared By (print)

Preparers Initials

Customer

Contact

Contacts Phone #

Date Prepared

INITIATOR INFORMATION
INITIATORS NAME

CHANGE REQUEST NO.

DATE

DEPARTMENT/COMPANY

TELEPHONE

FAX

E-MAIL

BASELINE DESCRIPTION
ORIGINAL PLAN

PROPOSED CHANGE
DESCRIPTION OF CHANGE

RATIONALE FOR CHANGE

MODIFIED ACTIVITIES
WBS NO.

ACTIVITY NAME/TITLE

WBS NO.

ACTIVITY NAME/TITLE

WBS NO.

ACTIVITY NAME/TITLE

OTHER REFERENCES

ESI

Change Request

IMPACT REVIEW
MEETING DATE

TECHNICAL IMPACT

BUDGET IMPACT

SCHEDULE IMPACT

PERFORMANCE IMPACT

CONTRACT IMPACT

APPROVALS
NAME (PRINT)

SIGNATURE

TELEPHONE

FAX

DATE

E-MAIL

CHANGE CONTROL BOARD (CCB) ACTION

SIGNATURE, CCB CHAIRPERSON

Approve and forward for customer concurrence

Deny
CUSTOMER DECISION
COMMENTS (IF APPROPRIATE)

Approved
Tabled
Disapproved
CUSTOMER SIGNATURE
NAME (PRINT)

SIGNATURE

TELEPHONE

FAX

ESI

DATE

E-MAIL