Appendix E - Example Change Request

DOE-STD-1073-2003

Configuration Management

APPENDIX E EXAMPLE CHANGE REQUEST

Change Request

Identification Number: ___________________________________________________

Title: __________________________________________________________________

Classification:

[ ] Safety SSC

[ ] Vital Safety System

[ ] Defense-in-Depth

[ ] Environmental

[ ] Mission Critical

[ ] Costly

[ ] Critical Software

[ ] adjacent SSC

Contacts

name

organization

phone

email address

number

Sponsor: (work

originator/requester/funder)

Design Engineer:

Cognizant System

Engineer(s):

Description of Proposed Change: (sufficient to support technical and management reviews add

pages if needed)

______________________________________________________________________________

_________________________________________________________________

Description of the potentially affected SSCs: ________________________________________

_______________________________________________________________________________

Reason for the proposed change: __________________________________________________

_______________________________________________________________________________

Schedule considerations: (any schedule constraints, such as maintenance outages when work is

to be performed or date by which work needs to be completed to support mission) _____

__________________________________________________________ _____________

Alternative solutions considered: _____________________________________

10.

Constraints: ______________________________________________________

11.

Any other information needed to review, track, or process the proposed change.

Approved for Change Control Review [ ] yes

[ ] no

____________________________________

Signature & date of approval authority

E-1