Attachment J.17 - Change_Request_form.docx
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- World Trade Center Health Program Clinical Centers of Excellence (CCE) - Draft Solicitation
- Solicitation number
- Draft_75D301-22-R-72142
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Change Control Request Change Request #1 Significant Change Request (with funding) # Contract No.
Contractor name and address:
Contractor point of contact:
Table of Contents
| INTRODUCTION | 3 |
| SCOPE OF SERVICES | 3 |
| APPROACH / PROPOSED CHANGES | 4 |
| INFRASTRUCTURE & CAPACITY REQUIREMENT | 4 |
| HARDWARE | 4 |
| SOFTWARE | 4 |
| NETWORK CONNECTIVITY | 4 |
| KEY RISKS, MITIGATION AND ASSUMPTIONS | 4 |
| RISKS | 4 |
| MITIGATION | 4 |
| ASSUMPTIONS | 4 |
| DELIVERABLES, ROLES & RESPONSIBILITIES | 5 |
| WORK ORDER SCHEDULE | 5 |
| EFFORT ESTIMATE & PRICING | 5 |
| REFERENCES | 5 |
| KEY CONTACTS | 5 |
| APPROVALS | 5 |
- 6 -
1. Introduction
Since its inception in July 1, 2011 the World Trade Center (WTC) Health Program has contracted with _________to provide __________________________services.
2. Approach / Proposed Changes
3. Infrastructure & Capacity requirement
3.1 Hardware
3.2 Software
4. Key Risks, Mitigation and Assumptions
· Risk:
· Mitigation:
· Assumption:
5. Deliverables, Roles and Responsibilities
6. Work Order Schedule Include work breakdowns and timeline.
7. Effort Estimate & Pricing
8. References
9.
10. Key Contacts
| Vendor Contact |
| Designation |
| Email, Phone & Fax No |
| NIOSH Contact |
| Designation |
| Email, Phone & Fax No |
11. Approvals
This Work Order version 1.0 is agreed and accepted by:
Contractor: ……………………………. NIOSH/WTC Health Program
By:
Name: Name:
| Title: | Title: |
| Date: | Date: |
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