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TOP THREE CONCEPT Change Request Form

Change Request Form

Change statement XXXXXX Requester/initiator Person submitting the
change request
Change Sponsor’s Change ID Number 001
name & signature (must match Change Log entry)
Date of Request Implementation by:

Change Request Detail - The Change Request form is the document of record for a change request.
Type(s) of Change:
Strategic direction People
Policy Supplier/Supplies
Project /production plan ICT/machine parts
Process/Procedure/Documentation Contract/orders
Product design/specification Regulatory Requirement
Organizational structure Other (please state):
Description of the change requested and rationale: Priority:
1 – Critical: “I can’t move forward until this change is resolved.”
2 – High: “I’m fine for right now, but unless this change is resolved by
the due date, I won’t be able to move forward.”
3 – Normal: “I’m 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.”

Change duration: Proposed Start date: Proposed End date:

Benefits of Proposed Change (The additional benefits the Alternatives (List any alternatives/work-around to the cha
proposed change would have):

Impact Severity
1 - Critical Impact: Requires normal operations shut down 3 - Normal Impact: Operations disrupted with manageable
2 - High Impact: Significant disruption to operation schedule, cost, or schedule and costs
quality 4 - Low Impact: Exposure is minimal to zero

Risk/Impact area & severity (e.g: CHANGE WILL CAUSE Control/mitigation plan: (e.g: REPLAN PRODUCTION SCHED
STOPAGE OF XYZ PLANT FOR APPROXIMATELY 15 HOURS) : CATER FOR BACKLOG)
1

3
 4

Does change affect allocation/reallocation of responsibilities Describe how?

and authorities? Yes No

Resources Required for Change:

Financial Impact ($) Estimated Cost of the Change:

1 Top Three’s Change Request Form

TOP THREE CONCEPT Change Request Form

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Change tracking method (time monitoring, periodic Change evaluation frequency:

testing, audit, inspection, verifications; data collection,
collation, analysis & reporting ) and frequency:

Reviewed by: Authorization

Who has the authority to approve this type of change?
Advisory Board Business Office
Steering Committee Customer/Stakeholder
Executive Sponsor Other:
Name Date Signature
Approved by: Change Requests Status
Change Request Open
Change Request Approved

Name Date Signature Change Request Rejected

Fiscal Review and Approval by Change Request Closed

If funding is sourced separately by a department

Deferred for review at later date Date:

Name Date Signature

 2 Top Three’s Change Request Form
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TOP THREE CONCEPT Change Request Form

Change Request Form

Change statement XXXXXX Requester/initiator Person submitting the
change request
Change Sponsor’s Change ID Number 001
name & signature (must match Change Log entry)
Date of Request Implementation by:

Change Request Detail - The Change Request form is the document of record for a change request.
Type(s) of Change:
Strategic direction People
Policy Supplier/Supplies
Project /production plan ICT/machine parts
Process/Procedure/Documentation Contract/orders
Product design/specification Regulatory Requirement
Organizational structure Other (please state):
Description of the change requested and rationale: Priority:
1 – Critical: “I can’t move forward until this change is resolved.”
2 – High: “I’m fine for right now, but unless this change is resolved by
the due date, I won’t be able to move forward.”
3 – Normal: “I’m 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.”

Change duration: Proposed Start date: Proposed End date:

Benefits of Proposed Change (The additional benefits the Alternatives (List any alternatives/work-around to the cha
proposed change would have):

Impact Severity
1 - Critical Impact: Requires normal operations shut down 3 - Normal Impact: Operations disrupted with manageable
2 - High Impact: Significant disruption to operation schedule, cost, or schedule and costs
quality 4 - Low Impact: Exposure is minimal to zero

Risk/Impact area & severity (e.g: CHANGE WILL CAUSE Control/mitigation plan: (e.g: REPLAN PRODUCTION SCHED
STOPAGE OF XYZ PLANT FOR APPROXIMATELY 15 HOURS) : CATER FOR BACKLOG)
1
 2

Does change affect allocation/reallocation of responsibilities Describe how?

and authorities? Yes No

Resources Required for Change:

Financial Impact ($) Estimated Cost of the Change:

1 Top Three’s Change Request Form

TOP THREE CONCEPT Change Request Form

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Change tracking method (time monitoring, periodic Change evaluation frequency:

testing, audit, inspection, verifications; data collection,
collation, analysis & reporting ) and frequency:

Reviewed by: Authorization

Who has the authority to approve this type of change?
Advisory Board Business Office
Steering Committee Customer/Stakeholder
Executive Sponsor Other:
Name Date Signature
Approved by: Change Requests Status
Change Request Open
Change Request Approved

Name Date Signature Change Request Rejected

Fiscal Review and Approval by Change Request Closed

If funding is sourced separately by a department
 Deferred for review at later date Date:

Name Date Signature

2 Top Three’s Change Request Form

submitting the

e is resolved by

mpact my ability

ove forward.”

ves/work-around to the change that exist):

disrupted with manageable extensions to

REPLAN PRODUCTION SCHEDULES TO

submitting the

e is resolved by

mpact my ability

ove forward.”

ves/work-around to the change that exist):

disrupted with manageable extensions to

REPLAN PRODUCTION SCHEDULES TO

 Click here to buy toolkit now
TOP THREE CONCEPT Change Request Form

Change Request Form

Change statement XXXXXX Requester/initiator Person submitting the
change request
Change Sponsor’s Change ID Number 001
name & signature (must match Change Log entry)
Date of Request Implementation by:

Change Request Detail - The Change Request form is the document of record for a change request.
Type(s) of Change:
Strategic direction People
Policy Supplier/Supplies
Project /production plan ICT/machine parts
Process/Procedure/Documentation Contract/orders
Product design/specification Regulatory Requirement
Organizational structure Other (please state):
Description of the change requested and rationale: Priority:
1 – Critical: “I can’t move forward until this change is resolved.”
2 – High: “I’m fine for right now, but unless this change is resolved by
the due date, I won’t be able to move forward.”
3 – Normal: “I’m 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.”

Change duration: Proposed Start date: Proposed End date:

Benefits of Proposed Change (The additional benefits the Alternatives (List any alternatives/work-around
proposed change would have):

Impact Severity
1 - Critical Impact: Requires normal operations shut down 3 - Normal Impact: Operations disrupted with m
2 - High Impact: Significant disruption to operation schedule, cost, or schedule and costs
quality 4 - Low Impact: Exposure is minimal to zero
Risk/Impact area & severity (e.g: CHANGE WILL CAUSE Control/mitigation plan: (e.g: REPLAN PRODUC
STOPAGE OF XYZ PLANT FOR APPROXIMATELY 15 HOURS) : CATER FOR BACKLOG)
1

Does change affect allocation/reallocation of responsibilities Describe how?

and authorities? Yes No

Resources Required for Change:

Financial Impact ($) Estimated Cost of the Change:

1 Top Three’s Change Request Form

TOP THREE CONCEPT Change Request Form

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Change tracking method (time monitoring, periodic Change evaluation frequency:

testing, audit, inspection, verifications; data collection,
collation, analysis & reporting ) and frequency:

Reviewed by: Authorization

Who has the authority to approve this type of change?
Advisory Board Business Office
Steering Committee Customer/Stakeholder
Executive Sponsor Other:
Name Date Signature
Approved by: Change Requests Status
Change Request Open
Change Request Approved

Name Date Signature Change Request Rejected

Fiscal Review and Approval by Change Request Closed

If funding is sourced separately by a department

Deferred for review at later date Date:

Name Date Signature

2 Top Three’s Change Request Form

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TOP THREE CONCEPT Change Request Form

Change Request Form

Change statement XXXXXX Requester/initiator Person submitting the
change request
Change Sponsor’s Change ID Number 001
name & signature (must match Change Log entry)
Date of Request Implementation by:

Change Request Detail - The Change Request form is the document of record for a change request.
Type(s) of Change:
Strategic direction People
Policy Supplier/Supplies
Project /production plan ICT/machine parts
Process/Procedure/Documentation Contract/orders
Product design/specification Regulatory Requirement
Organizational structure Other (please state):
Description of the change requested and rationale: Priority:
1 – Critical: “I can’t move forward until this change is resolved.”
2 – High: “I’m fine for right now, but unless this change is resolved by
the due date, I won’t be able to move forward.”
3 – Normal: “I’m 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.”

Change duration: Proposed Start date: Proposed End date:

Benefits of Proposed Change (The additional benefits the Alternatives (List any alternatives/work-around
proposed change would have):
Impact Severity
1 - Critical Impact: Requires normal operations shut down 3 - Normal Impact: Operations disrupted with m
2 - High Impact: Significant disruption to operation schedule, cost, or schedule and costs
quality 4 - Low Impact: Exposure is minimal to zero

Risk/Impact area & severity (e.g: CHANGE WILL CAUSE Control/mitigation plan: (e.g: REPLAN PRODUC
STOPAGE OF XYZ PLANT FOR APPROXIMATELY 15 HOURS) : CATER FOR BACKLOG)
1

Does change affect allocation/reallocation of responsibilities Describe how?

and authorities? Yes No

Resources Required for Change:

Financial Impact ($) Estimated Cost of the Change:

1 Top Three’s Change Request Form

TOP THREE CONCEPT Change Request Form

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Change tracking method (time monitoring, periodic Change evaluation frequency:

testing, audit, inspection, verifications; data collection,
collation, analysis & reporting ) and frequency:

Reviewed by: Authorization

Who has the authority to approve this type of change?
Advisory Board Business Office
Steering Committee Customer/Stakeholder
Executive Sponsor Other:
Name Date Signature
Approved by: Change Requests Status
Change Request Open
Change Request Approved
Name Date Signature Change Request Rejected

Fiscal Review and Approval by Change Request Closed

If funding is sourced separately by a department

Deferred for review at later date Date:

Name Date Signature

2 Top Three’s Change Request Form

 Person submitting the

nge request.

change is resolved.”
this change is resolved by

this may impact my ability

ability to move forward.”

osed End date:

y alternatives/work-around to the change that exist):

Operations disrupted with manageable extensions to

plan: (e.g: REPLAN PRODUCTION SCHEDULES TO
 Person submitting the

nge request.

change is resolved.”
this change is resolved by

this may impact my ability

ability to move forward.”

osed End date:

y alternatives/work-around to the change that exist):

Operations disrupted with manageable extensions to

plan: (e.g: REPLAN PRODUCTION SCHEDULES TO