Management Of Change Form
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2Management of Change Form
MANAGEMENT OF CHANGE
Page 1 of 1
Facility:
Process
Involved
Proposed Change Date:
Prepared By:
Title:
Date:
Type of Change - (circle one)
Chemical
Process Technology
Facility
Equipment
Procedural
DESCRIPTION OF
Summarize the technical basis for the
PROPOSED CHANGE
proposed change and any potential health and
AND POTENTIAL
safety impacts resulting from the proposed
HAZARDS
change. Indicate whether the proposed
change significantly affects safety or the
results of any previous hazard analysis. If
the change is temporary, indicate proposed
change start and end dates.
AUTHORIZATION TO PROCEED WITH
CHANGE
Authorized By:
Title
Signature:
Authorized Change Date:
PSM/RMP PROGRAM DOCUMENTATION
Circle
Completion
(To be completed prior to startup following change)
Answer
Date (if yes)
Have affected personnel (i.e., operations, maintenance,
and contract) been informed of and trained in this
change?
YES
NO
Are operating procedures or maintenance procedures
required to be updated as a result of this change?
YES
NO
If yes, have affected personnel been trained in the
updated operating procedures?
YES
NO
Is the PHA, Offisite Consequence Analysis, or RMP
applicability affected by this change?
YES
NO
If yes, has a hazard assessment update been performed
(if needed) and has the revised RMPlan been
submitted?
YES
NO
Is process safety information required to be updated
as a result of this change?
YES
NO
If yes, has a Prestartup Safety Review been
performed?
YES
NO
AUTHORIZATION FOR STARTUP
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