Change Management Form

Call Ticket No/CR No.____________

Emp. No: Branch Code:

First Name: Last Name:
Designation: Department:

Change Status Prepared Approved In Progress Completed Closed

(
)

Type of Change
Hardware: Up gradation Replacement Removal
Software: Up gradation New Installation Migration
Removal

Details of Change Request (attach sheet if required)

Proposed Change:

Reason for Change:

Activity Start Date Activity End Date

& Time and Time
Total Time IOS Version
Required
Hostname IP
Asset Code Switch/Router LAN
IP:
Switch/Router Priority: High/Medium/Low
WAN IP:
Implementation Required down time
Plan (attach sheet
is required) Backups

Technical docs

Passwords required

Other requirement
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 Change Management Form
Test Environment Details (attach sheet if required)
Testing Required Yes / No Tested on Test Yes / No
Environment
Hostname : OS
IP :
Database:- Database SID :-

Does it Require System Shutdown? Yes / No/NA

Does it Require to take backup of
Yes / No/NA
Configuration Data?
Does it have impact on all Bajaj Allianz
Yes / No/NA
LAN Segment?
Mention the impact, if applicable

Is it required to amend documentation /

Yes / No/NA
inventory?
Does it require Password for/from?
Was the change successful? Yes / No/NA
Problems, if any?

Rollback Needed? Yes / No/NA

Trigger point (Time to start rollback, if
any issue during implementation)
Rollback Plan / Procedure (Mandatory)
(attach sheet if required)
Permanent Limited Period
Period of Change If for limited period, tentative date to be
removed on DD / MM / YYYY

Approved By: Performed By: Checked By:

Signature Signature Signature

Name : Name : Name :
Date: DD / MM / YYYY Date: DD / MM / YYYY Date: DD / MM / YYYY

BA/FM/CNGMN/1.0 Page 2 of 2 Classified: Internal