Sample Change Control Form



Sample Change Control Form

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|Date of Request: |

| Change Request Initiator (name, location, phone): |

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|Description of Change: |

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|Reason for Change: |

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|How does the proposed change affect the safety vulnerabilities? (Safety, Health, and Environmental Considerations): |

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|Resulting Changes (to existing O&M procedures, inspection and testing procedures, process/facility documents/drawings, safety plans, training |

|requirements, etc.): |

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|Project Manager Approval (name and date): |

|Facility Operations Manager Approval (name and date): |

|Line Management Approval (name and date): |

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