Q-HSE AFRICA DEPARTMENT

CHANGE REQUEST FORM

Document N°: QUA-F-0042 Rev 02

Branch: Change request N°:

Date of request: Requested by:

A- Details of the request:

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

B- Origin of the request:

□ Malfunction / Incident □ Client’s requirement

□ New regulation / standard □ Safety improvement
□ Improvement, productivity, capacity □ Others:……………………………………………

C- Suggestion of change:

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

D- Admissibility of the request:

Requested by Concerned Manager
Validation □ Yes □ No
Date

Signature

If acceptance by the concerned manager, forward the document to the Q-HSE dpt. for the follow-up of the
change request.
 Q-HSE AFRICA DEPARTMENT
CHANGE REQUEST FORM
Document N°: QUA-F-0042 Rev 02

E- Preliminary Checklist:
Impact on the regulation: □ Yes □ No □ NA
Description of the impact – concerned documents:

Impact on the Quality of Service / product – clients requirements: □ Yes □ No □ NA

Description of the impact and associated action plan (to be annexed to the risk analysis)

Impact on Health, Safety, Security or the Environement: □ Yes □ No □ NA

Description of the impact and associated action plan (to be annexed to the risk analysis)

Impact on the Organisation: □ Yes □ No □ NA

Description of the impact and associated action plan (to be annexed to the risk analysis)

Impact on the documentation: □ Yes □ No □ NA

Description of the impact and associated action plan (to be annexed to the risk analysis)

Training needs: □ Yes □ No □ NA

Description of the impact and associated action plan (to be annexed to the risk analysis)
 Q-HSE AFRICA DEPARTMENT
CHANGE REQUEST FORM
Document N°: QUA-F-0042 Rev 02

F- Approbation of the change request:

Provide the applicable supporting information: Specifications, Budget, Forecast, Planning, maps, etc…

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................
Approved for immediate implementation

Approved only provided additional actions are taken

Rejected

Concerned HOD Q-HSE dpt. Managing Director Technical /

Maintenance
Date

Signature

Reserves of the Approval committee:

Provide the details of the reserves & associated corrective actions

G- Constitution of the Project team:

Name Role Responsibilities
A- Head of project
D- Project team:
1- Q-HSE department
2-
3-
4-
5-
6-
7-
* O : Operational, S : Support, I : Informed

H- Monitoring of the change request:

Steps of the implementation Supporting Realization Validated by
 Q-HSE AFRICA DEPARTMENT
CHANGE REQUEST FORM
Document N°: QUA-F-0042 Rev 02

documents date
Meeting
1- Project kick-off meeting
minute
2-

3-

4-

5-

6-

7-

8-

9-

10-

11-

12-

13-

14- Change closure meeting

I- Check and inspection before delivery

Head of project Head of Requesting Q-HSE dpt. Managing Director Service technique /
dpt. maintenance
Date

Signature

Reserves:
Details of the reserves and associated corrective actions