(Insert Your Agency Name Here

Agency Logo Optional)

______________________________________________________________________________

Project Name
Scope Change Request Form
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Prepared By: xxxxxxxxx

Date of Publication: mm/dd/yyyy

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 Add Project Name Here
Scope Change Request Form
Revision History
Version Date Author(s) Revision Notes
2012v1. 2012030 State of Maine Ten Step Standard Template customized
0 1 Project Management for State of Maine logos
Office

ii
Maine Project Management Office (insert file name here)
Copyright 2005-2008 TenStep, Inc. All Rights Reserved
 Add Project Name Here
Scope Change Request Form

Larger projects need more rigor and structure in how they raise and manage scope change
requests. The Scope Change Request Form is used to capture, screen, prioritize, and
evaluate scope change requests. Each form should be used to describe one specific scope
change request. Be sure to include enough information so that the request can be identified
and tracked, but not so much information that the form becomes a report. A summary of all
open and closed requests is kept in the Scope Change Log. (Remove this comment section
from final document.)

1
Maine Project Management Office (insert file name here)
Copyright 2005-2008 TenStep, Inc. All Rights Reserved
 Add Project Name Here
Scope Change Request Form

Project Name Scope Change Request Form

Scope Change Requested By: Date Reported:
Number:

Scope Change Scope Change Assigned To: Date Resolved:

Status:

Scope Change Description:

Business Benefit:

Implications of Not Making the Change:

Impact Analysis to the Project:

Alternatives:

Final Resolution:

Approval from Sponsor to Investigate (Optional):

Approval from Sponsor for Final Resolution:

2
Maine Project Management Office (insert file name here)
Copyright 2005-2008 TenStep, Inc. All Rights Reserved