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DEVIATION REQUEST FORM

Deviation Title: Date:

Deviation No:

Unit:

Document Reference:
Description of Deviation:

Corrective Action Proposed:

Deviation impacts on ( If yes, describe within Description of Deviation above)

Design/compatability with specified Yes/No Health, Safety & Yes/No


requirements Environmental factors
Availability Yes/No Life cycle cost Yes/No
Project schedule Yes/No Others Yes/No
Alternatives Considered :

CONTRACTOR APPROVAL FOR DEVIATION


Position Name Signature Date

Originator

Project manager

CLIENT APPROVAL FOR DEVIATION


Final Decision by Client
□ Approved □ Rejected
Note:

Name Signature Date

Format No: LTHE-SYN-G-FR-001