Change Request Impact Analysis
Avery Dennison – PMO
Change Control Sheet
Project Title: Siemens WO Number:
Siemens Project Manager:
CHANGE REQUEST – To be completed by requester
Requester: Date of request: Referenced attachments
(if applicable, imbed files using MSWord
menu item Insert/Object/Create From File)
Nature of change (e.g., schedule change, scope change, resource request):
Description of change:
Requested date to implement change:
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Change Request Impact Analysis
Avery Dennison – PMO
CHANGE EVALUATION – To be completed by Siemens PMO
Change request no:
Impacts/conflicts associated with implementing change:
Associated risks:
Pending customer requirements/inputs:
RECOMMENDATIONS – To be completed by Siemens PMO
Proposed approach to change:
Assumptions and constraints:
Cost to implement change: Timeline to implement change (including impacts to existing
timeline to accommodate change):
Name of evaluator: Date evaluated:
CHANGE APPROVAL – To be completed by Avery
Accepted Rejected Deferred Name Signature Date
Comments
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Change Request Impact Analysis
Avery Dennison – PMO
When to use this form:
Please complete and submit this form to the Avery PMO, when requesting a project change for any active
project not yet in production
For any change that materially changes the intent or direction of a project, do not use this form; instead,
please submit a revised Avery Solutions Questionnaire to the Avery PMO
What is a project change?
Any change to a deliverable date once the project schedule has been published
o This includes putting specific deliverables on hold, as well as later taking them off of hold
Any change (increase or decrease) to project scope or quality
Any change in project resource requirements
Cancellation of a project anytime after its WO is approved
o This includes cancelling remaining deliverables after a project has been partially implemented
Any material change to a server in-scope for an active project
Process flow:
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