Project Change Request Form (template 1)

Request Submission Information:

Project Name:
Name of Authorized Requestor:

Date requested:

Title of Authorized Requestor:

Request Number

__/__/____

Department/Division:
Description of change requested

Expected benefit of the change

Stakeholder

Value Added Description

Value-Added Amount

Implementation Requirements

Cost of Implementation

Low

High

1.
2.
2.
4.

Total

Return on Investment
Annual savings (revenue enhancement or cost reductions)
Cost of implementation

1st Year Savings

Return on Investment (1st year) (1st year savings devided by cost)

Person authorizing the request

Authorizor's Name

Associated signiture
Authorizor's Signiture

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Below are the definitions of the information to be placed in each field of the Project Change Request Form.
Product Definition:

The Project Change Request is the first part of a 2-part packet designed to support the evaluating
tracking of a suggested modification to a project's scope. The Project Change Request contains
information provided by the person making the request. The 2-part packet goes through three ph
first phase is the "Request" phase, the second phase is the "Impact Analysis" phase and the third
the "Approval-Denial" phase. The 2-part packet is designed to drive the change request process
become a permanent record of each specific request.

Project Change Request Form

Request Submission Information:
Project Name:
Name of Authorized Requestor:
Title of Authorized Requestor:
Department/Division:

Date requested:
Request Number

Description of change requested

Describe the details of the change being requested. Be sure to attach examples of any screens
that are part of the request. Explain why the change is justified. Be as specific as possible. Foc
benefits and the value the change provides to the organization.

Expected benefit of the change

Stakeholder
Place the name of the
Stakeholders or Stakeholder
Groups here (Sales, customer,
owners, etc.).

Value Added Description

Describe with as much detail as possible how this
change benefits each Stakeholder listed. Add
attachments if needed.

Implementation Requirements

Describe any implementation requirements you are aware of such as training, scheduling, equip
purchases and all related time tables. If specialists are needed be sure to identify them and the
expected to play in the effort.

Cost of Implementation
1. Detail each cost component of the change. Provide the description on the lines
2. provided (add attachments if needed).
2.
4.

Return on Investment
Annual savings (revenue enhancement or cost reductions)
Cost of implementation (average of above total)

1st Year Savings

Return on Investment (1st year)

Authorizor's Name

Authorizor's Signiture

roject Change Request Form.

ned to support the evaluating and

ect Change Request contains
packet goes through three phases. The
Analysis" phase and the third phase is
the change request process and to

Date requested:
Request Number

__/__/____

attach examples of any screens or reports

Be as specific as possible. Focus on

scription

as possible how this

lder listed. Add

Value-Added Amount
Enter the dollar value
benefit of the change
for each Stakeholder
listed.

ch as training, scheduling, equipment

be sure to identify them and the role they are

>> These fields

are self
explanatory

tion on the lines

Total

Low
High
Enter
Enter
the high
the low
estimated estimated
cost
cost
$
$
$

1st Year Savings

nvestment (1st year)

Authorizor's Signiture

0
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