Change Request Form Template

National Project Management System
Business Projects-IT-Enabled

Change Request Form

How to complete Change Request (CR):

  1. Complete each field.
  2. When completed, save document ensuring filename is the same as the Change Request title.
  3. Keep one copy for your records and e-mail one copy to MANAGER who will assign a Change request # AND add to the change request log.

CR Number:
(Change manager to assign)

Admin

Requester:

Date Submitted:

Associated Risk No.

Associated Issue No.

Change Type: (Circle all that apply)

  • Scope 
  • Budget 
  • Time 

Change Request Details

CR Title:

Description:
Explain the change. Include impact to schedule, cost, scope, etc.Attachments:

Reason for Change:
Explain why change is required. Attach/embed documents, if necessary.
Attachments:

Results of Impact Analysis:
Provide summary of impact analysis. Attach/embed documents, if necessary.
Attachments:

Estimate Summaries:

Estimated Cost ($)

Estimated Effort (Days)

Estimated Duration (Days)

Complete within Allotted Budget? (Y/N)

Approvals

Recommendation to Implement Change:

NAME

DATE

YES

NO

PSC Approval

Name/Title

Signature

Date

Closure

Change Outcome:
Provide summary/outcome of implemented change.

Date closed:

Lessons Learned:

Is there a lesson to be learned from this CR?