1.	General Information

Information to be provided in this section gives a specific name to the project as well as pertinent information about the personnel involved.

Project Name:	Date:
Project Number:	Modification Date:
Prepared by:	Change Control #:

2.	Requestor Information

2.1	Proposed Change Request Description and References:

The requestor will provide information concerning the requested change along with any supporting documentation.

<Proposed change>

2.2	Justification:

<Justification>

2.3	Impact of Not Implementing Proposed Change:

<Impact>

2.4	Alternatives:

<Alternatives>

3.	Initial Review Results of the Change Request

Initial Review Date: __________	Assigned to: _______________

Approved for Impact Analysis

Reject

Defer Until:

Reason:

<Reason>

4.	Initial Impact Analysis

Baselines Affected:

<Baselines>

Configuration Items Affected:

<Configuration Items>

Cost/Schedule Impact Analysis Required?

Yes	No

Impact on Cost:

<Impact cost>

4.5	Impact on Schedule:

<Impact schedule>

4.6	Impact on Resources:

<Impact resources>

Final Review Results:

<Final results>

Review Date:

<Review date>

4.9	Classification:

High	Medium	Low

5.	Impact Analysis Results

5.1	Specific Requirements Definition:

<Definition>

Additional Resource Requirements	Work Days	Cost

Impact of Not Implementing the Change:

<Impact>

Alternatives to the Proposed Change:

<Alternatives>

Final Recommendation:

<Final recommendation>

6.	Signatures

Reviewing Body:

Name/Title	Signature	Date

Commonwealth of Pennsylvania	4.F_CRF_Final

Department of Environmental Protection

Change Request Form

<Enter Project Name Here>

1 of 3	7/28/2006

<Location of Project "file path">

Commonwealth of Pennsylvania

mmcdaniel

2005-10-04