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Design Change Request Form 2013-08 Rev 2

This document is a design change request form for an MBTA project. It collects information about the proposed design change such as a description of the change, why the original design needs to be changed, potential impacts to cost, schedule, and operations. It requires concurrence from several levels of management, including the Director of Design, Director of Project Controls, Area Director, Chief Engineer of Design & Construction, and Assistant General Manager of Design & Construction depending on the cost of the change. It also lists required attachments to support the change request.

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Amjid Ali
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136 views5 pages

Design Change Request Form 2013-08 Rev 2

This document is a design change request form for an MBTA project. It collects information about the proposed design change such as a description of the change, why the original design needs to be changed, potential impacts to cost, schedule, and operations. It requires concurrence from several levels of management, including the Director of Design, Director of Project Controls, Area Director, Chief Engineer of Design & Construction, and Assistant General Manager of Design & Construction depending on the cost of the change. It also lists required attachments to support the change request.

Uploaded by

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

DESIGN CHANGE REQUEST FORM

PROJECT NAME

CONTRACT #

CHANGE REQUEST #

WBS #

DATE

DATE REQUIRED

1. DESCRIPTION OF PROPOSED CHANGE:

2. BASIS OF ORIGINAL DESIGN:

3. WHY WAS CHANGE NOT ANTICIPATED?

4. JUSTIFICATION OF PROPOSED CHANGE:

Rev 2-08.2013

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5. TECHNICAL/OPERATIONS IMPACT:

6. IMPACT IF CHANGE REQUEST NOT APPROVED:

7. SCHEDULE IMPACT:
a) DESIGN:

b) CONSTRUCTION:

8. COST IMPACT:
a) DESIGN:

b) CONSTRUCTION:

Rev. 2-08.2013

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9. THIS CHANGE WILL REQUIRE?

AMENDMENT
TASK ORDER
BUDGET REALLOCATION
TRANSFER AMENDMENT
10. CLASSIFICATION LEVEL:

DIRECTOR
CHIEF ENGINEER OF D&C
ASSISTANT GM FOR D&C
GENERAL MANAGER
SECRETARY OF TRANSPORTATION
BOARD OF DIRECTORS
ASSISTANT GM FOR D&C

$0 - $25,000
>$25,000 - $100,000
>$100,000 - $250,000
>$250,000 - $5,000,000
>$5,000,000 - $15,000,000
>$15,000,000
TIME EXTENSION

SUBMITTED BY:

DATE

TITLE:
STATEMENT OF CONCURRENCE:
DESIGNER
:

DATE

TITLE:

Rev. 2-08.2013

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SIGNATURE:
DIRECTOR OF DESIGN

Concur

Not Concur

Concur

Not Concur

Approved

Not Approved

Approved

Not Approved

Approved

Not Approved

______
DATE

COMMENTS:

SIGNATURE:

______
DATE

DIRECTOR OF
PROJECT CONTROLS
COMMENTS:

SIGNATURE:
AREA DIRECTOR

DATE

COMMENTS:

SIGNATURE:
CHIEF ENGINEER OF
DESIGN & CONSTRUCTION

DATE

COMMENTS:

SIGNATURE:
AGM OF DESIGN
& CONSTRUCTION

DATE

COMMENTS:

Rev. 2-08.2013

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REQUIRED ATTACHMENTS:
DESIGN EXTRA WORK ORDER REQUEST LETTER AT AUTHORIZED LEVEL
CMS REPORT CMS-PS-020 - ACTION LIMIT SUMMARY
INDEPENDENT COST ESTIMATE
DESIGN CHANGE REQUEST LOG

Rev. 2-08.2013

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