change order form template

Project Name

Project Number

Project Manager

Today's Date*

Requestor

First Name

Last Name

Project Owner

Describe the Requested Change

Describe the Reason for the Request

Risk Identification/Analysis

Impact Analysis

Work products to be modified (with version numbers)

Additional Quality Assurance or Quality Control Activities

Describe the impact of the change to quality assurance activities and quality control activities.

New Deliverables Description

Required Hours

Date Required

Impact to Other Delivery Dates

Required Hours

Date Required

Impact to Other Delivery Dates

Required Hours

Date Required

Impact to Other Delivery Dates

Based on the impact, state the estimated date for implementing the requested change. State the new estimated project completion date.

New Deliverables Description

Lessen or Eliminate Other Expenses? Please describe.

Cost of New Deliverable

Lessen or Eliminate Other Expenses? Please describe.

Cost of New Deliverable

Lessen or Eliminate Other Expenses? Please describe.

Cost of New Deliverable

Describe the overall impact to budget/cost.

Checkbox

Approved Approved with modifications Rejected Deferred

Justifications

Additional Comments

Reviewer's Name

First Name

Last Name

Reviewer's Titles

Review Date*