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|  DOE-STD-1073-2003
Configuration Management
Example Change Control Package
1.
Identification Number (from Change Request): _______________________________
2.
Title: ___________________________________________________________________
3.
Classification:
[ ] Safety SSC
[ ] Defense-in-Depth
[ ] MEL
[ ] Environmental
[ ] Mission Critical
[ ] Costly
[ ] Critical Software
[ ] adjacent SSC
4.
Contacts and Authorities:
Name
Organization
Phone
Email address
number
Sponsor: (work
originator/requester/funder)
Design Engineer:
Cognizant System
Engineer(s):
Technical Review Lead:
Management Review Lead:
Independent Design
Reviewer:
Approval Authority:
Individual responsible for
implementation of the
approved change:
Individual responsible to
approve final completion of
change
5.
Description of Proposed Change: (sufficient to support technical and management reviews)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6.
Location: (Site/Area/Building/Room)______________________________________________
7.
Change Request Form is complete, verified accurate, and attached? [ ]
8.
Deviations from current design requirements: ______________________________________
Technical Review
9.
Identify technical review team members and their organizations, applicable experience and
knowledge. (attached sheet)
F-2
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