Example Change Control Package cont'd

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)

Name Org

Phone Email

Operations

ALARA

ES&H

Maintenance

Security

OSHA

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