Office of Administration / Office for Information Technology [OA/OIT] OPD-SYM010a Blackout / Freeze Form, November 2013
General Information For completion by the requester and e-mailed to the ra-oanetworkchange@pa.gov Prior to the start of the requested Blackout / Freeze Window.
Date	Requesting Agency, Commission, Council or Service Provider
Click here to select a date.	Enter requesting organization / company name.
Primary and Secondary Contacts
Contact Name	Contact Telephone Number	Contact Cell Phone Number	Contact Internet E-Mail Address
Enter Primary Contact’s full name.	Enter Primary Contact’s Telephone number.	Enter Primary Contact’s Cell Phone Number.	Enter Primary Contact’s Internet e-mail address.
Enter Secondary Contact’s full name.	Enter Secondary Contact’s Telephone number.	Enter Secondary Contact’s Cell Phone Number.	Enter Secondary Contact’s Internet e-mail address.
TIMELINE	Start Date	Start Time	End Date	End Time
Blackout / Freeze Window	Click here to select a date.	Click here to select a time.	Click here to select a date.	Click here to select a time.
Select from a limited blackout / freeze or a comprehensive blackout / freeze.	Click here to select the type of blackout / freeze being requested.
DESCRIPTION OF REQUEST
Enter all services potentially impacted by maintenance scheduled during this Blackout / Freeze Window. If the request is specific to a known infrastructure path or service, describe the path or details.
OA/OIT reserves the right to approve and implement change/s that do not impact the service defined herein. The above contact/s will be consulted if a change could potentially impact the service defined herein.
The section below is for completion by the Functional and Enterprise Change Managers OA/OIT Functional Change Management and Enterprise Change Management Approval
Services	Enter all service areas, including network infrastructure and applications to which no service impacting maintenance is to be performed during this Blackout / Freeze.
Approval Recommendation	Click here to select an approval recommendation.
Date	Click here to select a date.
Comments	Enter all comments, conditions and previously scheduled maintenance that will proceed as scheduled.