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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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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
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
Please note that this checklist template is a hypothetical example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
Please, finish the registration to access the content of the checklist.