CHANGE REQUEST FORM

Project Title:	[Insert Name of Project]
Submitted By:	[Insert Requestor's Name]	Date:	[Insert Date]
Brief Description of Change Being Requested:
[Description of Change Request]
Reason/Causes for Change (External events, omission or error in the plan, adding value to the project’s product, implementation of a contingency plan or workaround)
[Describe Reason for the Change]
Impact on Scope
[Describe Impact on Scope]
Impact on Cost
[Describe Impact on Cost]
Impact on Schedule
[Describe Impact on Schedule]
Impact on Quality
[Describe Impact on Quality]
Project Manager’s Evaluation and Recommendation on: [Date of Recommendation]
[Describe Recommendation]
Sponsor/Sr. Management Decision on: [Date of Mgmt. Approval]
[Describe Decision - Approval or Disaprove]
IT Change Management Policy/Process Reviewed:	[Yes or No]
[Describe Needed Action for IT Change Control]

CHANGE REQUEST FORM INSTRUCTIONS

When we encounter problems on projects, there are two general courses of action. The first that we explore is corrective action, where we solve problems without the need to modify the project plan. If corrective action cannot resolve the issue we follow the change request process, which is always documented in the project plan.

The Change Request Form should describe the change that is being requested, the justification for that change, and the cost of that change in terms of dollars, duration and the impact of the change on scope.

Project Title – Specify a name for the project to be called by the organization.

Submitted By – The name of the person who is requesting a change to the project.

Date – The date the requestor asked for the change.

Brief Description of Change Being Requested – Describe what the change will be for the project. For example, the duration will be extended 2 weeks and the budget will increase by $10,000.

Reason/Causes for Change – Describe why the requestor is asking for the change. For example, a stakeholder becomes ill and will be off the project for the next 2 months. Resources will have to be acquired in order to fulfill the tasks assigned to the original resource.

Impact on Scope – Describe the impact the change request has on the scope of the project. For example, is one of the deliverables changing or is a new deliverable being added to the project.

Impact on Cost – Describe the impact the change request has on the budget of the project.

Impact on Schedule – Describe the impact the change request has on the baseline, schedule, of the project. For example, the task on the critical path will be extended by 5 days.

Impact on Quality – Describe the impact the change request has on the quality of the project. For example, has the quality of the deliverable changed?

Project Managers Evaluation and Recommendation – The project manager(s) will specify his/her recommendation for the change request and date.

Sponsor / Senior Management Decision – The sponsor(s) will specify if they approve or disapprove the change request and date.

IT Change Management Policy/Process Reviewed – The project manager(s) will need to determine if the requested change needs to follow the IT Change Management Policy.

CHANGE REQUEST FORM EXAMPLE

Project Title:	Electronic Medical Record Evaluation Project
Submitted By:	David Gabriele	Date:	11/23/05
Brief Description of Change Being Requested:
Change the GE vendor demonstration date of the Centricity EMR 2005 product from 11/29 to 12/12.
Reason/Causes for Change (External events, omission or error in the plan, adding value to the project’s product, implementation of a contingency plan or workaround)
GE was originally schedule for a demonstration on 11/29. SOM executives requested that the demonstration be moved to another date since a conflict existing with the SOM Strategic Planning Retreat. Several executives, including physicians, would not be able to attend the demonstration due to this schedule conflict. In order to have a fair analysis of both EMR vendor solutions the project teams’ members must be able to compare both products.
Impact on Scope
No impact on Scope – does not affect any major deliverables or objectives.
Impact on Cost
No impact on Cost
Impact on Schedule
Schedule will be directly impacted by moving the GE vendor demonstration to a later date – 12/12/2005.
Impact on Quality
No impact on Quality
Project Manager’s Evaluation and Recommendation on: 11/28/05
The Project Manager recommends that the GE demonstration occur on the new date of 12/12/05. GE was contacted to move the date to an earlier date but no GE demonstration resources were available for the prior week, only the original week of 11/28. A GE demonstration of their new 2005 version EMR product is crucial to the delivering the Project’s Product (Recommendation of EMR System to be used at all SOM sites). The recommendation is to move the demonstration to 12/12/05 with an impact of delaying the final deliverable of the recommendation to 02/21/06 from 01/31/06.
Sr. Management/Sponsor Decision on: 11/30/05
Willie Miska approves recommendation.
IT Change Management Policy/Process Reviewed:	[Yes or No]
[Describe Needed Action for IT Change Control]