Georgia Technology Authority

Change Request form

[ Insert Project Name]

Change Request Number and description[DEC1]:
Basis for Change and Impact to Project[DEC2]:
Change Request Title[DEC3]: / Priority (Indicate with an X[DEC4])
Project Area: [DEC5] / Critical
/ High
/ Medium
/ Low
Sponsored by[DEC6]: / Verified By[DEC7]: / Date Submitted[DEC8]:
Status[DEC9] / Outcome[DEC10]
Submitted
/ Evaluated
/ Approved
/ Closed
/ Rejected
/ Deferred
Preferred Resolution[DEC11]:
Implications of Not Making the Change[DEC12]:
Schedule / Timing Change[DEC13]
Resource Change[DEC14]
Source of Resource[DEC15] / Additional Hours Required[DEC16] / Resources Available[DEC17] / Comments[DEC18]
Financial Change[DEC19]
Financial Type[DEC20] / Original Estimate[DEC21] / Revised[DEC22] Estimate / Comments[DEC23]

Project Manager Acceptance[DEC24]

Approved Disapproved

Name / Signature / Date

Business Owner Acceptance

Approved Disapproved

Name / Signature / Date

Actual Resolution and Other Remarks[DEC25]:

Change Request FormPage 1 of 2

[DEC1]Write a general description of the change request

[DEC2]Write a general description of why this change is necessary and how it will impact the project – schedule, cost, quality, deliverables, etc.

[DEC3]Give a name for this change request

[DEC4]Place an X in the proper box to indicate the priority of this change request

[DEC5]Indicate the project area such as deliverable

[DEC6]Enter name of sponsor

[DEC7]Enter name of individual verifying the contents of this change request

[DEC8]Enter the date the change request is submitted

[DEC9]Enter the current status of the change request. Update with each new version.

[DEC10]Enter the final disposition of the change request

[DEC11]Describe the preferred resolution from the viewpoint of the individual submitting the change

[DEC12]List the implications if the change is not approved.

[DEC13]If the change request impacts the schedule or timing of deliverables, enter the change requested to the schedule for example – deliverable # x will be 2 weeks late or the baseline end date of the project will be esxtended by 2 weeks

[DEC14]If the change request impacts resources give a brief description here and complete the fields below

[DEC15]Where will the resources come from if the change requires new resources

[DEC16]How many additional hours will be neeced

[DEC17]Suggest sources of resources if there are any available

[DEC18]Add any additional comments necessary to describe resources

[DEC19]If the change request impacts cost, give a brief description here and complete the fields below

[DEC20]Use any financial codes required for this change

[DEC21]Insert the baseline cost estimate here

[DEC22]Insert the revised cost estimate here

[DEC23]Add any additional comments necessary to explain this change.

[DEC24]Check approved or disapproved by PM and Business owner

[DEC25]When complete use this section to add information on the actual resolution and add any other remarks necessary.