Management of Change (MOC) 

Checklist*
 
The purpose of Management of Change (MOC) is to ensure that changes are 
recognized, documented, formally reviewed, and approved by qualified personnel prior 
to their implementation in order to avoid potential safety or operational problems and to 
comply with federal and provincial regulations. *​Edit this template to suit your specific 
needs. 
 
 
By:  
Updated:  
 
Part 1: Change Description 
 
Who is requesting the  enter text 
change (names/titles)?
Write a summary of the  enter text 
requested change:

enter text 
List the affected 
equipment/machinery:
enter text 
List the affected 
jobs/roles:
List the affected  enter text 
procedures, tests, 
and/or inspections:

List the affected  enter text 

reactive 
chemicals/materials, if 
applicable: 

 
Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 
 
What areas will be improved by the change?  

1. Safety & Health  Yes  No  N/A  Comments 

2. Environment  Yes  No  N/A  Comments 

3. Loss Prevention  Yes  No  N/A  Comments 

4. Operations  Yes  No  N/A  Comments 

5. Human Resources  Yes  No  N/A  Comments 

What is the proposed length of change?  

6. Emergency (Initiate and Finalize as  Yes  No  N/A  Comments 
soon as possible) 

7. Permanent  Yes  No  N/A  Comments 

8. Temporary (Include length of time  Yes  No  N/A  Comments 

in comments) 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 What Type of Change is Proposed?  
9. Facility Additions or Modifications  Yes  No  N/A  Comments 
(Include details in comments) 

10. Equipment Change or Modification  Yes  No  N/A  Comments 

(Include details in comments) 

11. Work Practices or Best Practices  Yes  No  N/A  Comments 

(Include details in comments) 

12. IT/Computers/Systems (Include  Yes  No  N/A  Comments 

details in comments) 

13. Subcontractor (​ Include details in  Yes  No  N/A  Comments 

comments) 

14. Role Change ​(Include details in  Yes  No  N/A  Comments 
comments) 

15. Procedure/Process/Method/Opera Yes  No  N/A  Comments 

tion (​ Include details in 
comments) 

16. Chemical/Contaminant/Product  Yes  No  N/A  Comments 

(Include details in comments) 

17. Personnel Addition or Removal  Yes  No  N/A  Comments 

(Include details in comments) 

18. Policy or Standard (​ Include details  Yes  No  N/A  Comments 

in comments) 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 19. Documentation or Records  Yes  No  N/A  Comments 
(Include details in comments) 

20. Individual’s Role or Job  Yes  No  N/A  Comments 

Description ​(Include details in 
comments) 

21. Other (​ Include details in  Yes  No  N/A  Comments 

comments) 

What Hazards are Involved in this Change?  

22. Biological  Yes  No  N/A  Comments 

23. Chemical/Contaminant/Product  Yes  No  N/A  Comments 

24. Stored Energy/Electrical/Gas  Yes  No  N/A  Comments 

25. Preparation/Training/Skills  Yes  No  N/A  Comments 

26. Access/Egress  Yes  No  N/A  Comments 

27. Emergency Planning  Yes  No  N/A  Comments 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 28. Ergonomic  Yes  No  N/A  Comments 

29. Physical/Cuts/Burns/etc.  Yes  No  N/A  Comments 

30. Confined Space  Yes  No  N/A  Comments 

31. Psychological  Yes  No  N/A  Comments 

32. Has a complete change risk  Yes  No  N/A  Comments 

assessment been performed? 

 
   

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
Part 2: MOC Initiation & Change Approval 
 
33. Do you have a MOC  Yes  No  N/A  Comments 
Leader/Coordinator ready to run 
point on this change? 

34. Do you have knowledgeable  Yes  No  N/A  Comments 

change reviewers ready to review 
the proposed changes? 

35. Do you have a change finalizer, if  Yes  No  N/A  Comments 
different from MOC Coordinator? 

36. Does the description of the  Yes  No  N/A  Comments 

proposed change and all affected 
systems provide enough 
information? 
37. Have you identified all affected  Yes  No  N/A  Comments 
roles and personnel? 

38. Have you identified all affected  Yes  No  N/A  Comments 
contractors and temporary 
personnel? 

39. Has a change request been  Yes  No  N/A  Comments 

submitted? 

40. Has a change request been  Yes  No  N/A  Comments 

reviewed? 

41. Has a change request been  Yes  No  N/A  Comments 

approved? 

42. Have process engineering,  Yes  No  N/A  Comments 

technician, or manager personnel 
been consulted, if needed? 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 43. Has an equipment specifications  Yes  No  N/A  Comments 
and Maintenance/Parts technician 
consulted, if needed? 

44. Will you be able to comply with all  Yes  No  N/A  Comments 
Federal, State, and Local safety 
and engineering standards during 
this change? 

45. Have all potential hazards and  Yes  No  N/A  Comments 
gaps been reviewed and 
discussed? 

Change Final Approval Process 

 
46. List all the reviewers who have  Enter Text 
reviewed the change: 

47. List all concerns brought up by  Enter Text 

reviewers: 

48. Have concerns been addressed?  Yes  No  N/A  Comments 

How? 

49. Has the change been approved?  Yes  No  N/A  Comments 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 50. Has the change been initiated?  Yes  No  N/A  Comments 

51. Date of Initiation  Enter Text 

 
   

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
Part 3: Pre-Startup Safety Review 
 
52. Pre-startup Safety Review (PSSR)  Yes  No  N/A  Comments 
conducted? 

53. Did the PSSR expose any new,  Yes  No  N/A  Comments 
existing, or potentially existing 
hazards? 

54. Have all known new, existing, or  Yes  No  N/A  Comments 
potentially existing hazards been 
evaluated and mitigated? 
55. Training Program completed or  Yes  No  N/A  Comments 
updated? 
56. Training methods provided:  Yes  No  N/A  Comments 
one-on-one or independent review 

57. Training methods provided: group,  Yes  No  N/A  Comments 

presentation or classroom setting 

58. Training methods provided: group,  Yes  No  N/A  Comments 

hands-on learning 

59. New job/role procedures written  Yes  No  N/A  Comments 

and approved? 

60. New tests/inspections written  Yes  No  N/A  Comments 

and approved? 

61. Have all affected personnel been  Yes  No  N/A  Comments 
notified and trained on the 
change? 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 62. Have all affected contractors  Yes  No  N/A  Comments 
been notified and trained on the 
change? 

63. Have all Work Plans, HASPs,  Yes  No  N/A  Comments 
Procedures, Policies, MOC history 
page, and Documentation been 
updated? 

64. Have you updated your  Yes  No  N/A  Comments 

emergency plan, if applicable? 

65. Has the change review team  Yes  No  N/A  Comments 
reviewed the PSSR? 

66. Has startup been approved?   Yes  No  N/A  Comments 

 
   

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
Part 4: Post-Startup Evaluation & Change Finalization 
 
67. Have new safety audits been  Yes  No  N/A  Comments 
conducted? 

68. Have gaps in safety procedures or  Yes  No  N/A  Comments 
audits been identified and 
addressed? 
69. Have all affected personnel been  Yes  No  N/A  Comments 
asked to provide feedback after the 
change?  

70. Have all gaps in training been  Yes  No  N/A  Comments 
addressed?  

71. Have all gaps in emergency and/or  Yes  No  N/A  Comments 
special procedures been resolved?  

Change Finalization 
 
72. Has the change been fully  Yes  No  N/A  Comments 
implemented? 

73. Has MOC been fully documented?   Yes  No  N/A  Comments 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.  
 

  
 
 74. Has the change been reviewed for  Yes  No  N/A  Comments 
effectiveness? 

75. Was this change effective?  Yes  No  N/A  Comments 

76. Is the change accomplishing its  Yes  No  N/A  Comments 

original intent? 

 
Temporary Change Resolution 
 
77. Has the temporary change been  Yes  No  N/A  Comments 
returned to its normal status? 

78. Has the temporary change been  Yes  No  N/A  Comments 
made permanent?  

79. Was the temporary change  Yes  No  N/A  Comments 

effective? 

Report hazards in real-time with ​Safesite​. Get it for free on ​desktop​, i​ OS​, or A
​ ndroid​.