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Management of Change Form

This document is a management of change form for a proposed change at a facility. The form requires describing the proposed change, any potential safety hazards, and whether it significantly affects previous hazard analyses. It must be authorized before proceeding and confirm that affected personnel have been trained, procedures updated, and a pre-startup safety review conducted if needed.

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119 views2 pages

Management of Change Form

This document is a management of change form for a proposed change at a facility. The form requires describing the proposed change, any potential safety hazards, and whether it significantly affects previous hazard analyses. It must be authorized before proceeding and confirm that affected personnel have been trained, procedures updated, and a pre-startup safety review conducted if needed.

Uploaded by

dila
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Management 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


Authorized By: Title:

Signature: Authorized Start-Up


Date:

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