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Client Code *

Requested For

Description of the Issue *

When was this problem detected? *

:

Other affected components

Provide us with relevant example (s) (ACC#/AE title/user name)

What version (s) was used to reproduce the problem?

How is this problem affecting your workflow? *

Do you have a practical workaround?

Any additional information you can provide?

What is the urgency of the issue reported? *

Change Category (Minor) *

Review Type (Minor) *

Account Request Type *

Phone Number: *

Service Impacted *

Action #1 *

Action #2 *

Action #3 *

Failover Action *

Name *

Email *

Ticket Category *

Subject *

Change Point of Contact *

Short Description *

Change Description *

**Sensitive Data Only**

Sensitive Data This field is to be used to input mission sensitive data that will not be included in unencrypted email notifications. Do not enter Patient Information, only items like IP Addresses.

Reason for Change Explain why the change is necessary, e.g., compliance, efficiency, bug fix, customer requested or security improvement.

Environment Impacted *

Systems Impacted Provide full host name, environment (Pre-Prod / Prod), & system role. (Ex: VAC20CCANTP000, Pre-Prod, SQL Server)

Service or Application Impacted Ex: Load Balancing Services, Workflow Orchestration (WFO) Application,...

Product & Category *

Nature of the Change Clarify if this is an upgrade, replacement, new feature, patch, configuration change, etc.

Change Info / Release Notes [System/Component Name] Version [Old Version] to [New Version] or configuration specifics, application release notes.

Backups Required

Backup Request Details List systems (provide full host name) requiring backups ran prior to change implementation. Ex: VAC20CCANTP000

Impact to Operations * Functional & Cybersecurity impact., including any expected down time required to implement the change.

Post-Change Verification Plan Plan to test that all primary functions of the system, application, or service are working as expected.

Rollback Plan Outline the steps and contingencies to revert a system, service or application to its pre-change state if the change fails or introduces unacceptable issues.

CCB Meeting Scheduled Date & Time When inputting time, enter Eastern Time Zone time. Scheduled date and time for CCB meeting to review Major changed requests.

:

CCB Attendees List of who attended the CCB meeting.

CCB Meeting Minutes Minutes to include action items are recorded for each CCB meeting by the System steward. Minutes are to be posted to eMASS as an artifact.

**Eastern Time**

Start Time - Requested date and time of change * When inputting time, enter Eastern Time Zone time.

:

End Time - Requested date and time of change * When inputting time, enter Eastern Time Zone time.

:

Change Category (Major) *

Review Type (Major) *

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