Title of Proposed Change:	Date Created:
Originator Name:	CD Unit:
Business Requirement(s) and Detailed Description of Proposed Change:
Justification: (please check all that apply)
Child Safety Issue Federal Requirement State Requirement Financial Issue	Policy Issue Best Practice Issue Usability Issue
Other (explain)
Authorizations (please print name, sign & date):
Originator:
Direct Supervisor:
Circuit Manager:
Regional Director:
Deputy Director: