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Management of Change Form Template

The change management form must be signed by all responsible persons to confirm the approval of the changes to be implemented. Safety representatives can adapt this template to include a documentation list required for the safe implementation of changes.

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Management of Change Form Template

Information

Initiator of proposed change

Discription of suggested change

Area of Change

Suggested Date and Time to implement Change?

MOC Form

Does the involved personnel (e.g. operations, maintenance, contractors, etc.) require notification or training associated with this change?

Are operating or maintenance procedures required to be updated as a result of this change?

Does P&ID or other drawings need updating based on change?

Is the Offsite Consequence Analysis, PHA or Emergency Response Procedures impacted by this Change?

Does the Process Safety Information require updating as a consequence of this change?

If the change includes new equipment, have the Mechanical Integrity and testing inspection requirements been updated accordingly

Other impacts to this Process? (if Yes, list on notes)

Are training and communications completed?

Was Pre-Startup Safety Review (PSSR) completed with this change?

Are any other actions required as part of this change?

Completion of MOC

Further comments

Operations/Facility: Full name and signature

Building Facility: Full ame and signature

Area Supervisor: Full name and signature

Bldg. or Utility Operations Engr: Full name and signature

Safety Officer: Full name and signature

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