Management of Change Form Template

Use this Management of Change Form Template to assess, document and approve changes of processes or systems, to avoid any safety or operational problems.​

Management of Change Form Template



Change Finalization

1. Has the change been fully implemented?


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2. Has MOC been fully documented?


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3. Has the change been reviewed for effectiveness?


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4. Was this change effective?


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5. Is the change accomplishing its original intent?


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Temporary Change Resolution

1. Has the temporary change been returned to its normal status?


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2. Has the temporary change been made permanent?


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3. Was the temporary change effective?


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Change The Description

1. Who is requesting the change (names/titles)?


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2. Write a summary of the requested change:


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3. List the affected equipment/machinery:


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4. List the affected jobs/roles:


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5. List the affected procedures, tests, and/or inspections:


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6. List the affected reactive chemicals/materials, if applicable:


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Areas Of Improvement

1. Will Safety & Health be improved by the change?


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2. Will the Environment be improved by the change?


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3. Will Loss Prevention be improved by the change?


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4. Will Operations be improved by the change?


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5. Will Human Resources be improved by the change?


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Proposed Length Of Change

1. Is it an emergency (initialized and finalized as soon as possible)?


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2. Is it permanent?


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3. Is it temporary? And what is the time taken for the change?


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Type Of Change

1. Are facility additions or modifications changed?


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2. Is there an equipment change or modification?


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3. Are there changes to work practices or best practices?


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4. Are there changes in IT/Computers/Systems?


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5. Is there a subcontractor change?


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6. Has there been a role change?


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7. Have there been changes to procedures/processes/methods/operations?


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8. Are there changes in chemicals/contaminants/products?


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9. Have personnel been added or removed?


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10. Have there been changes to policies or standards?


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11. Have documentation or records been changed?


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12. Has an individual's role or job description changed?


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Hazards Involved In Change

1. Are biological hazards involved in this change?


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2. Are there chemical/contaminant/product-related changes?


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3. Is there a change related to stored energy/electrical/gas?


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4. Are there changes in preparation/training/skills?


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5. Are there changes in access/egress?


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6. Are there changes in emergency planning?


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7. Are there ergonomic changes?


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8. Are there changes related to physical injuries such as cuts/burns/etc.?


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9. Are there changes related to confined space?


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10. Are there changes affecting psychological aspects?


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11. Has a complete risk assessment been performed for this change?


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MOC Initiation & Change Approval

1. Is there a MOC Leader/Coordinator ready to run point on this change?


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2. Are there knowledgeable change reviewers ready to review the proposed changes?


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3. Is there a change finalizer, if different from the MOC Coordinator?


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4. Does the description of the proposed change and all affected systems provide enough information?


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5. Have all affected roles and personnel been identified?


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6. Have all affected contractors and temporary personnel been identified?


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7. Has a change request been submitted?


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8. Has a change request been reviewed?


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9. Has a change request been approved?


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10. Have process engineering, technicians, or manager personnel been consulted if needed?


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11. Has an equipment specifications and Maintenance/Parts technician been consulted, if needed?


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12. Will the organization be able to comply with all Federal, State, and Local safety and engineering standards during this change?


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13. Have all potential hazards and gaps been reviewed and discussed?


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Change Final Approval Process

1. List all the reviewers who have reviewed the change: (enter text field)


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2. List all concerns brought up by reviewers:(enter text field)


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3. How have the concerns been addressed? (enter text field)


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4. Has the change been approved?


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5. Has the change been initiated?


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6. What is the date of initiation? (enter text field)


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Pre-startup Safety Review

1. Has a Pre-startup Safety Review (PSSR) been conducted?


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2. Did the PSSR expose any new, existing, or potentially existing hazards?


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3. Have all known new, existing, or potentially existing hazards been evaluated and mitigated?


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4. Is the training program completed or updated?


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5. Have training methods provided one-on-one or independent reviews?


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6. Have training methods provided: group, presentation, or classroom setting?


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7. Have training methods provided: group, hands-on learning?


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8. Are new job/role procedures written and approved?


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9. Are new tests/inspections written and approved?


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10. Have all affected personnel been notified and trained on the change?


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11. Have all affected contractors been notified and trained on the change?


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12. Have all Work Plans, HASPs, Procedures, Policies, MOC history page, and Documentation been updated?


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13. Has the emergency plan been updated, if applicable?


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14. Has the change review team reviewed the PSSR?


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15. Has the startup been approved?


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Post-Startup Evaluation & Change Finalization

1. Have new safety audits been conducted?


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2. Have gaps in safety procedures or audits been identified and addressed?


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3. Have all affected personnel been asked to provide feedback after the change?


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4. Have all gaps in training been addressed?


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5. Have all gaps in emergency and/or special procedures been resolved?


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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