Instructions for Design Change Request Form

Project Name: Self-explanatory.

Contract #: Self-explanatory (also place in header of 2nd page).

Change Request #: This number will be filled in by PM. The forms will be numbered consecutively as they are received and will be entered into the Change Request Log (also place in header of 2nd page).

WBS #: Work Breakdown Structure Number(s) affected by the change.

Date: Originator enters the date for the submission of the Change Request.

Date Required: Originator enters the estimated date approval is needed to avoid adverse impacts on technical performance, schedule, cost or quality/safety.

Description of Proposed Change: Describe the change requested. Use the continuation page, as required.

Basis of Original Design: What was the original intent/purpose of the project?

Justification of Proposed Change: Justify the proposed change. Describe the problem or defect that will be corrected by the proposed change. Indicate the experience that dictates the need for the change. Summarize the capability to make the change. Include the impact if the change is not approved. Use the continuation page, as required.

Change Impact Assessment: Provide a statement of impact to technical performance, schedule, cost, and quality/safety. Use the continuation page, as required.

Schedule Impact (Design): Identify current schedule data date. List current design milestone (s) and end dates. Describe how this action will affect current design milestone (s).

Schedule Impact (Construction): List anticipated construction advertising date and milestone. How will this action impact the anticipated advertising and milestone date?

Cost Impact (Design): Identify current design budget. How will this action affect the current design budget?

Cost Impact (Construction): Identify current construction budget. How will this action affect current construction budget? This number can be approximated.

Amendment: Change to a contract.

Transfer Amendment: Transfer funds between one or more contract actions, new scope.

Task Order: Change to an established contract with a maximum price.

Rev. 2-08.2013 Budget Reallocation: Reallocates funds within one contract action; does not involve new scope.

Classification Level: Authorization Level.

Statement of Concurrence: Signature of Designer is required.

Signature Approvals: Based on the Change Request classification, the appropriate authorization signee must provide a signature.

Rev. 2-08.2013