Change Request Impact Analysis

Avery Dennison – PMO

Change Control Sheet

Project Title: Siemens WO Number:
Siemens Project Manager:

CHANGE REQUEST – To be completed by requester

Requester: Date of request: Referenced attachments
(if applicable, imbed files using MSWord
menu item Insert/Object/Create From File)

Nature of change (e.g., schedule change, scope change, resource request):

Description of change:

Requested date to implement change:

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 Change Request Impact Analysis
Avery Dennison – PMO

CHANGE EVALUATION – To be completed by Siemens PMO

Change request no:
Impacts/conflicts associated with implementing change:

Associated risks:

Pending customer requirements/inputs:

RECOMMENDATIONS – To be completed by Siemens PMO

Proposed approach to change:

Assumptions and constraints:

Cost to implement change: Timeline to implement change (including impacts to existing

timeline to accommodate change):

Name of evaluator: Date evaluated:

CHANGE APPROVAL – To be completed by Avery

Accepted Rejected Deferred Name Signature Date

Comments

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 Change Request Impact Analysis
Avery Dennison – PMO

When to use this form:

 Please complete and submit this form to the Avery PMO, when requesting a project change for any active
project not yet in production
 For any change that materially changes the intent or direction of a project, do not use this form; instead,
please submit a revised Avery Solutions Questionnaire to the Avery PMO

What is a project change?

 Any change to a deliverable date once the project schedule has been published
o This includes putting specific deliverables on hold, as well as later taking them off of hold
 Any change (increase or decrease) to project scope or quality
 Any change in project resource requirements
 Cancellation of a project anytime after its WO is approved
o This includes cancelling remaining deliverables after a project has been partially implemented
 Any material change to a server in-scope for an active project

Process flow:

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