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DOE-STD-1073-2003
Configuration Management
25.
Does the change involve a USQ?
[ ] yes [ ] no
26.
If the change does involve a USQ, has it been approved by DOE?
[ ] yes
27.
Identify the methods and acceptance criteria for the post-modification testing (attach).
28.
Are all other required reviews complete (identify in table below)?
[ ] yes
Assigned reviewer
Area
Req'd
Comments
Signature/date
(yes/no)
(yes/no)
Name  Org
Phone  Email
Operations
ALARA
ES&H
Maintenance
Security
OSHA
QA
Training
Management
System
Other
29.
Identify and track the changes to the documents affected by the change in the table below.
Documents include safety analyses; TSRs; hazard and accident analyses; USQ determinations;
authorization bases; studies, analyses, and calculations performed to support the change; SDDs; MELs;
MDLs; field change requests (FCRs); setpoint tables; M&TE database; maintenance lists; procurement
specifications; spare parts lists; procedures; training materials; drawings; diagrams; sketches; manuals; ISM
descriptions; QAPs; and implementation plans.
Document
Req'd to
Tracking
New
Affected
Contact
Document update
operate
No.
Rev.
pages/
complete and
No.
sections
distributed
No.
Title
yes  no
(print name, initial,
date)
30.
Specify any installation conditions or instructions related to the change. _________________
_______________________________________________________________________________
_______________________________________________________________________________
31.
Has the implementing organization reviewed the change and confirmed it can be
implemented as proposed?
[ ] yes
________________________________________________
__________________
Signature of approval authority to authorize implementation
date
________________________________________________
__________________
Signature of authorized individual certifying completion
date
F-4


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