IT Change Control Form

Todays Date:

Submitted by:

Type of Change: (Planned, Emergency/Break-Fix)

Short Description:

Change Owner:

Lead Implementer:

Proposed Date:

Duration:

Risk Level: (High, Medium, Low)

Type of Change: (Infrastructure, Network, Application, Security)

Conflict with other changes? (Y/N) Transparent to users? (Y/N)

Vendor Support Needed? (Y/N, name of vendor and availability)

List out Servers(s), Site(s), Care Center(s) Affected:

Activities and/or functions that will not be available during this change:

Activities communicated to affected users/community and how? (internal, external, vendors)

Tested in non-production environment: (Y/N)

Tested by:

Long Description of the Change: (task list with time estimates)

Change Validation Activities: (list of activities with name of tester)

Backout/Rollback Procedure: (task list with time estimates)

Change Reviewed:

Change Approved: (YES, NO)

If NO, please provide details:

IT Change Control

Submission Form

Change Control Form v1

Last Updated:8/7/2015

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