Change Request Form (example)
[This form is divided into three sections. Section 1 is intended for use by the individual submitting the
change request. Section 2 is intended for use by the Project Manager to document/communicate their
initial impact analysis of the requested change. Section 3 is intended for use by the Change Control
Board (CCB) to document their final decision regarding the requested change.]
1.) SUBMITTER - GENERAL INFORMATION
CR# [CR001]
Type of CR ☐ Enhancement ☐ Defect
Project/Program/Initiative
Submitter Name [John Doe]
Brief Description of [Enter a detailed description of the change being requested]
Request
Date Submitted [mm/dd/yyyy]
Date Required [mm/dd/yyyy]
Priority ☐ Low ☐ Medium ☐ High ☐ Mandatory
Reason for Change [Enter a detailed description of why the change is being requested]
Other Artifacts Impacted [List other artifacts affected by this change]
Assumptions and Notes [Document assumptions or comments regarding the requested change]
Comments [Enter additional comments]
Attachments or ☐ Yes ☐ No
References Link:
Approval Signature [Approval Signature] Date Signed [mm/dd/yyyy]
2.) PROJECT MANAGER - INITIAL ANALYSIS
Hour Impact [#hr [Enter the hour impact of the requested change]
s]
Duration Impact [#dy [Enter the duration impact of the requested change]
s]
Schedule Impact [WB [Detail the impact this change may have on schedules]
S]
Cost Impact [Cos [Detail the impact this change may have on cost]
t]
Comments [Enter additional comments]
Recommendations [Enter recommendations regarding the requested change]
Approval Signature [Approval Signature] Date [mm/dd/yyyy]
Signed
3.) CHANGE CONTROL BOARD – DECISION
Decision ☐ Approved ☐ Approved ☐ Rejected ☐ More Info
with Conditions
Decision Date [mm/dd/yyyy]
Decision Explanation [Document the CCB’s decision]
Conditions [Document and conditions imposed by the CCB]
Approval Signature [Approval Signature] Date Signed [mm/dd/yyyy]
UP Template Version: 11/30/06 Page 1 of 2
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UP Template Version: 11/30/06 Page 2 of 2
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