📍 When to use this template
- When a client, consultant, or site team proposes a change from the original plan or GFC drawing.
- Triggered whenever a Change Request (CR) is formally raised to evaluate its consequences.
- Filled by the Project Manager or Planning Engineer, with input from Execution, QS, and Safety teams.
Sections & fields
Preview of the template structure. Download Excel to fill on site.
1Header / Project Information7 fields
Project Name
_____________
Contract / Package No.
_____________
Document No.
_____________
Date of Assessment
_____________
Change Request (CR) Ref. No.
_____________
Prepared By (Name & Designation)
_____________
Approved By (Name & Designation)
_____________
2Description of Proposed Change6 fields
Change Title
_____________
Originator of Change (Client/Consultant/Contractor)
_____________
Date of Change Request
_____________
Detailed Description of Change (What is being changed?)
_____________
Reason / Justification for Change (Why is it needed?)
_____________
Reference Drawings / Documents (Old vs. New)
_____________
3Impact on Project Schedule (Time Impact Analysis)6 fields
Activities Affected (from Baseline Schedule)
_____________
Estimated Delay / Acceleration (in days)
_____________
Impact on Critical Path (Yes/No/Potential)
_____________
Revised Milestone Dates
_____________
Need for Extension of Time (EOT) Claim (Yes/No)
_____________
Supporting Documents (Primavera/MSP extract, S-Curve)
_____________
4Impact on Project Cost (Cost Impact Analysis)6 fields
Estimated Cost Increase / Decrease (in INR)
_____________
Rate Analysis Reference (DSR/Market/Quoted)
_____________
Bill of Quantities (BOQ) Items Affected
_____________
Impact on Project Cash Flow
_____________
Variation Order (VO) / Extra Item Required (Yes/No)
_____________
Budget Head Affected
_____________
5Impact on Quality & Technical Specifications5 fields
Change in Material Specifications (BIS/Make)
_____________
Change in Workmanship / IS Codes
_____________
Impact on Performance / Functional Requirements
_____________
Need for Mock-up / Sample Approval
_____________
Revised Method Statement / ITP Required (Yes/No)
_____________
6Impact on Safety, Health & Environment (SHE)5 fields
New Hazards Introduced
_____________
Revised HIRA / JSA Required (Yes/No)
_____________
Impact on BOCW Compliance (e.g., new scaffolding, excavation)
_____________
Environmental Clearance Impact
_____________
Waste Management Plan Impact
_____________
7Impact on Other Project Areas4 fields
Impact on Subcontractors / Vendors
_____________
Impact on Site Logistics / Access
_____________
Impact on Statutory Approvals
_____________
Impact on Interface with Other Packages/Contractors
_____________
8Recommendation & Approval5 fields
Overall Impact Assessment (Low/Medium/High)
_____________
Recommended Action (Approve/Reject/Revise)
_____________
Comments / Mitigation Measures Proposed
_____________
Signature of Project Manager
_____________
Signature of Client / Engineer-in-Charge
_____________
💡 Sample filled excerpt
Change Title: Shifting of UG Tank location due to unforeseen hard rock. Impact on Schedule: 15 days delay to critical path activity 'UG Tank Raft Casting'. EOT claim required. Impact on Cost: Increase of INR 2,50,000 due to extra rock excavation and PCC. VO to be raised. Recommendation: Approve change, as it is unavoidable. Proceed with EOT and VO claim submission.
⚖ Compliance notes
- Helps in substantiating claims for Variation (VO) and Extension of Time (EOT) as per FIDIC Sub-Clauses 13.1 (Right to Vary) and 8.4 (Extension of Time for Completion).
- Aligns with the process for handling deviations and extra items described in the CPWD Works Manual.
- Provides a clear audit trail for change management, crucial during project closure and final bill settlement.
- A fundamental document for maintaining control over project scope, time, and cost (the 'triple constraint').