MOC REQUEST FORM Form Number: 2025/TS/QA/MO/006 Employee ID(Required)Employee Name(Required)Position Description(Required)Phone Number(Required)Department(Required)CEO Office Section(Required)EM Section(Required)Operations Section(Required)HR , ADMIN & IT Section(Required)HSE Section(Required)Finance Section(Required)TS Section(Required)COD Section(Required)MOC No #(Required)Request Date(Required) MM slash DD slash YYYY Requested By:(Required)Department(Required)Priority(Required)Change type(Required) Permanent Temporary Emergency Personnel Change Request Description(Required)Reason For the Change(Required)Alternative Options, if any(Required)For Permanent / Temporary / Emergency / Personnel ChangesRequired Start Date(Required) MM slash DD slash YYYY Required End Date(Required) MM slash DD slash YYYY End Date Extension(Required) MM slash DD slash YYYY Extension Authorized by(Required)(Temporary change is valid for 6 months. If required, it can be extend to next 3 months with re-review as 1st Extension and further it can be extend to another 3 months as 2nd Extension.)For Temporary / Emergency Changes1st ExtensionStart Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY Extension Authorized by(Required)2nd ExtensionStart Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY Extension Authorized by(Required)Policy & Procedure/Work Instructions, Plan Attached.(Required)Policy & Procedures and Work Instructions Approved by Technical Review Committee(Required)Documentation Updates Required (Specify)Policy & Procedures(Required)Work Instructions(Required)P&IDs / GA Drawings(Required)Software’s (if applicable)(Required)Equipment Spec Sheets(Required)PHA/HAZOP Checklist or Risk Assessment Form(Required)Any Other Documents(Required)Is a PHA (Process Hazard Analysis) or HAZOP (Hazard & Operability Study) Review or Risk Assessment required? (Refer to PHA/HAZOP Checklist) (If PHA/HAZOP/ Risk Assessment is required kindly forward to HAZOP & Risk Assessment Committee to complete PHA/HAZOP Checklist or Risk Assessment form) PHA / HAZOP Review:(Required) Yes No Risk Assessment:(Required) Yes No Justification(Required)Initiated By(Required)Impact Assessment – Technical Review Committee (Note : Write NA wherever Not Applicable)Write Comments / Recommendations For Each/h3>Quality Assurance /MR(Required)Date(Required) MM slash DD slash YYYY Quality Control(Required)Date(Required) MM slash DD slash YYYY Operational Planning(Required)Date(Required) MM slash DD slash YYYY Mechanical Maintenance(Required)Date(Required) MM slash DD slash YYYY General Maintenance(Required)Date(Required) MM slash DD slash YYYY Electrical & Instrumentation(Required)Date(Required) MM slash DD slash YYYY Operations(Required)Date(Required) MM slash DD slash YYYY HSSE & SS(Required)Date(Required) MM slash DD slash YYYY Commercial &Warehouse(Required)Date(Required) MM slash DD slash YYYY Finance(Required)Date(Required) MM slash DD slash YYYY HR & Admin / GS / IT(Required)Date(Required) MM slash DD slash YYYY Is a PHA/HAZOP Checklist / Risk Assessment Enclosed :(Required) Yes No Not Applicable If Yes, Close out of Action Items & Recommendations of PHA-HAZOP Review or Risk Assessment : Yes No RecommendationsRecommendations / Approval - Technical Review Committee Head ( CTO )(Required)Recommendations / Approval for Design or Construct– CEO(Required)Pre-Startup Safety Review (PSSR): The following issues have been resolved and the undersigned believe the Process/facility is ready for startup, as per the following:The construction and equipment meet design specifications(Required) Yes No NA For new facilities, the initial Process Hazard Analysis has been performed, and recommendations have been resolved.(Required) Yes No NA PHA/HAZOP Checklist or Risk Assessment updated and recommendations have been resolved or implemented before startup.(Required) Yes No NA Employees trained on Change Procedures.(Required) Yes No NA Changes made to modify the process/facility have been reviewed and authorized under the Management of Change Program.(Required) Yes No NA Safety, operating, maintenance and emergency procedures are in place, and adequate.(Required) Yes No NA Policy & Procedures(Required) Yes No NA Work Instructions(Required) Yes No NA P&IDs / GA Drawings(Required) Yes No NA Software’s (if applicable)(Required) Yes No NA Equipment Spec Sheets(Required) Yes No NA PHA/HAZOP Checklist or Risk Assessment Form(Required) Yes No NA Other Documentation(Required) Yes No NA Follow-up Activities & Close Out:Has the change been carried out as required?(Required) Yes No Not Applicable Has the change met expectations?(Required) Yes No Not Applicable Have all relevant personnel been adequately trained?(Required) Yes No Not Applicable All Review Recommendations addressed.(Required) Yes No Not Applicable For Temporary MOC, Ensure that the Plant/all operating conditions are returned back to normal following completion of the test run objectives(Required) Yes No Not Applicable Has all relevant documentation been updated & Close-Out of Action Items (if any)(Required) Yes No Not Applicable
