MOC Health, Safety and Environmental Impact Checklist
MANAGEMENT OF CHANGE – CHANGE APPROVAL FORM
ROUTING: INITIAL FINAL
MOC #__________________________
Initial Approval - Please, review, initial and date the “ Initial Approval/Date” column and forward to next
on list.
Final sign-off – Please review, sign and date the “Final Approval Signature” and “Date” columns to close
the MOC and forward to next on the list.
Approval Requirements:
Reviewer: Print Name: Initial Approval / Final Approval Date:
Date Signature
Originator
MOC Coordinator(s)
Flow Manager
HS&E
Representative
Engineering
Representative
Maintenance
Quality Assurance
Representative
Plant Manager
Return to MOC Coordinator
Page 1 of 5
MOC Health, Safety and Environmental Impact Checklist
Management of Change – Change Approval Checklist
MOC Number: Change Description/Reference: Department:
Model Shop
MOC Originator: Issue Date:
Complete Date:
Permanent Change Temporary Change Emergency Change
Effective Date if a Temporary Change -- From: To:
If temporary change extended, another MOC will need to be initiated with a reference to original MOC number
Describe the chemical, process, procedure, facility or equipment modification.
This mill increases part dimensional capabilities in the Model Shop.
The MOC Coordinator completes the following section and forwards to the review route list.
Does this Statement Apply? Y/N If Yes, Complete
The change requires new manufacturing processes, new or modified equipment, piping,
Sections A.1 – A.6
instrumentation, cooling systems, electrical components, relocation of equipment or alteration of and C.1 – C.7
traffic patterns.
Review with SG
The change involves facility expansions, renovations or any modification requiring a local Risk Manager.
construction permit. Consider GAPS
review.
The change involves the introduction of new chemicals or the production of byproducts that may Sections B.1 - B.3
result in exposure to personnel or a release to the environment. and C.1 - C.7
The change will require revisions to procedures and/or new or additional training for supervisors,
Section D.1
operators, staff or contractors?
Other? Sections that apply:
_____________
Attach appropriate backup details
Section A.1 Guarding and Equipment Hazards. Could the change:
A2.i result in point of operation, pinch point or power transmission hazards? YES NO
A.2.ii require the need for electrical interlocks on doors, panels or guards? YES NO
A.2.iii affect access to equipment lubrication and adjustment points? YES NO
A.2.iv affect standard operating temperature, pressure or flow rate? YES NO
A.2.v alter, affect or bypass a safety device? YES NO
A.2.vi alter, affect or bypass an alarm system? YES NO
A2.vii create the need for grounding, ground fault protection or arc flash review? YES NO
Resource: HPM Machine Guarding Checklist
Page 2 of 5
MOC Health, Safety and Environmental Impact Checklist
Section A.2 Controls. Could the change:
A3.i result in the need for emergency stops or automatic shutdowns? YES NO
A.3.ii create a need for the control panel to be protected from inadvertent activation? YES NO
A.3.iii create a need for additional controls labeling or illumination of controls? YES NO
A.3.iv create a need for warning lights or alarms? YES NO
Section A.3 Other Equipment and Facility Health and Safety Considerations. Could this change:
A4.i Create ergonomic risks such as awkward postures, excessive force (push/pull, lift/lower), repetition YES NO
or vibration, temperature, noise, adjustability or lighting.
Ergonomics Resources:
A.4.ii present ergonomic risk s from displays that are difficult to read; controls that are difficult to distinguish YES NO
or are not consistent among work stations; unclear labeling; more controls than necessary to do the job
A.4.iii create special equipment anchorage or stabilization requirements? YES NO
A.4.iv introduce any access, egress, slip, trip or fall hazards? YES NO
A.4.v require updates to operating procedures, facility drawings, maintenance schedules or personal YES NO
protective equipment requirements?
Section A.4 Physical Security, Information Security and Parking Considerations. Could this change:
A5.i create a need for additional access control measures; such as fences, secure doors, motion YES NO
detectors, or signs?
A.5.ii create a need for additional hardware, software or procedural techniques to protect computer YES NO
networks or other information systems?
A.5.iii impact parking? YES NO
A.5.iv create a need for additional security lighting? YES NO
A.5.v create a need for additional access keys or access cards? Are these additional keys and cards YES NO
properly controlled?
Section A.5 Detail HS&E action(s) required for the new manufacturing process or equipment or facility modifications.
Address hazards identified above.
Action Items Responsibility Target Date Actual
Completion Date
Page 3 of 5
MOC Health, Safety and Environmental Impact Checklist
Section B New Chemicals
Section B.1 List new chemicals & attach Materials Safety Data Sheet (MSDS) copy.
B.1.i
B.1.ii
Section B.2 Hazard Identification. Could the change:
B.2.i increase the risk of exposure to workers or release to the environment? YES NO
B.2.ii create an explosive or flammable mixture? YES NO
B.2.iii alter chemical toxicity, corrosivity or reactivity? YES NO
B.2.iv affect standard operating temperature or pressure? YES NO
B.2.v require additional spill control or containment? YES NO
B.2.vi require the use of a carcinogenic material, reproductive hazard or other toxic material? YES NO
B.2.vii require an update to the site Toxic Risk Management Program (TORIMAN)? YES NO
B.2.viii require an update or modification to the site emergency response procedures; such as RCRA YES NO
Contingency Plan, Storm Water Pollution Prevention Plan, or Spill Prevention Control and Counter-
measures Plan?
B.2.viii alter the facility status with respect to EPA Risk Management Program, OSHA Process Safety YES NO
Management Program, Department of Homeland Security Chemical Anti-Terrorism Standards?
B.2.ix require an update to hazardous substance reportable quantity discharge or spill reporting notices YES NO
posted at the site?
B.2.x alter the facility status with respect to SARA (Emergency Planning and Community Right to Know) YES NO
and create a need for notification to the SERC, submittal of MSDS to state and local emergency response
organizations or annual submittal of a Toxic Release Inventory Form R?
Section B.3 Action(s) required to use specified new chemicals
Action Items Responsibility Target Date Actual
Completion Date
Section C Environmental Aspects and Impacts
If the facility is ISO 14001 compliant or actively pursuing ISO 14001 certification:
If you answer “YES” to any of the questions in Section C, then a review of your ISO 14001 4.3.1 Aspects Matrix should be
completed to determine if there is a need to alter or add to current facility aspects and impacts.
C.1 Air Emissions. Could this change:
C.1.i produce air emissions? YES NO
C.1.ii require an air permit, permit modification or notification to the State regulatory agency? YES NO
C.1.iii require air pollution controls? YES NO
C.1.iv require the use or purchase of ozone depleting substances? YES NO
C.2 Water Discharges. Will this change:
Page 4 of 5
MOC Health, Safety and Environmental Impact Checklist
C.2.i result in a wastewater, sanitary or storm water discharge or a change to water discharge flow rates? YES NO
C.2.ii require a permit, permit modification or notification to a local wastewater treatment facility or State YES NO
regulatory agency?
C.2.iii require new or additional pre-treatment? YES NO
C.3 Storage Tanks. Will this change:
C.3.i result in the installation of underground storage tanks? YES NO
C.3.ii result in the installation of tanks to store hazardous waste or hazardous materials, petroleum YES NO
products or propane?
C.4 Waste Generation. Will this change:
C.4.i produce a waste or recyclable material? YES NO
C.4.ii produce a hazardous waste? YES NO
C.4.iii require special waste handling, abatement or disposal measures be implemented? YES NO
C.5 Energy Usage. Will this change:
C.5.i affect facility energy usage? YES NO
C.6 Other Environmental Considerations.
C.6.i Have recycling options and costs been considered? YES NO
C.6.ii Does the change create land disturbances? YES NO
C.6.iii Does the change impact the surrounding community (e.g. noise, odor)? YES NO
C.7 Detail environmental actions required for the new equipment or process, chemical or facility modification.
Action Items Responsibility Target Date Actual
Completion Date
Section D.1 Training and/or New Procedure Requirements
D.1.i Does the change require new or revised procedures? YES NO
D.1.ii Does the change require posting of a new or revised Lockout procedure on the equipment? YES NO
D.1.iii Does the change create a need for new or additional training for supervisors, operators, staff or YES NO
contractors?
Action Items Responsibility Target Date Actual
Completion Date
Page 5 of 5
