New Jersey Department of Transportation
Capital Project Support	Form DES-RQST-2

Design Change Request	
Forward to Change Control Board Administrator	
Project Manager	     	Telephone	     	
Designer	     	Submittal Date	     	
Program Manager  	     	Concur     	Date	     	
Route and Section	
     
	
Description of Change	
     
	
Reason for and Value of Change, Advantages and Disadvantages	
     
	
Recommendation:	
     
	
Has the change been reviewed by other offices or CPC Screening Committee? (If yes, list office and contact person)	
     
	
FHWA/State Involvement	 Full Oversight	 Alt. Procedures	 100 % State	
Cost Breakdown	
Original Design Cost
     	Total Previous Revisions
     	Current Revision
     	Total Design Cost
     	
Construction Cost 	ROW Cost 	Total Non-Design Cost 	
Original	Incr./Decr.	Original	Incr./Decr.	Increase/Decrease	
     	     	     	     	     	
Director of Project Management	
              Concur (CCB meeting is necessary)      	

	

	

	

Signature:	

Date:	

	

	

	
	
Director, Division of Project Management	

	

	

	
- OR -   Recommend for approval without CCB meeting based on the following justification and with the following conditions:	
	
     	

	

	

	

	

	

	

	

	

	

	

Signature:	

Date:	

	

	

	
	
Director, Division of Project Management	

	

	

	

CCB Decision for Route 	

	

	

	

	

	

	

	

	

	

	
Change Control Board Meeting Date (if held) ______________	

Assistant Commissioner of Capital Program Management	

	

	

Concurrence:	

Date:	

	

	

	
	
Richard T. Hammer	

	
	
Assistant Commissioner	

	
	
Capital Program Management