Change Order Templates

The following are samples to be used for the change order and change order memorandum forms. Use these examples cautiously. The examples are for guidance and general format only. For instance, the examples contain assumptions that may or may not fit actual project situations. Also, the Standard Specifications (PDF) and special provisions in use at the time the examples were written are the basis for the example change orders.

Note: Do not assume that your project uses the same specifications. Base change orders on specifications included in the project.

For more information regarding change orders and methods of payment, refer to Section 5-3, "Change Orders," (PDF) of the Construction Manual .

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Crude Oil Price Adjustment

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Payment adjustment at agreed unit price:
In accordance with Section 9-1.07, "Payment Adjustments for Price Index Fluctuations," of the Standard Specifications, compensation payable for the bid item(s) listed below will be adjusted whenever the California statewide crude oil price index for the month the material is placed is more than 5 percent higher or lower than the price index at the time of bid.

Item No.	Item Description
Item 1	Item 1 Description
Item 2	Item 2 Description
Item 3	Item 3 Description

The adjustment in dollars per ton of asphalt used to produce materials placed in the work is calculated as follows:
A = [(Iu / Ib) - 1.05] x Ib x [1 + (T / 100)] for an increase in the crude oil price index exceeding 5 percent

A = [(Iu / Ib) - 0.95] x Ib x [1 + (T / 100)] for a decrease in the crude oil price index exceeding 5 percent

Iu = California statewide crude oil price index for the month in which the asphalt was placed
Ib = California statewide crude oil price index for the month in which the bid opening occurred
T = Sales and use tax rate currently in effect in the tax jurisdiction where the material is placed

For this work, the contractor shall receive and accept $0.00. This sum constitutes full and complete compensation for this change.

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Payment adjustment for price index fluctuations

Reason for change:
The California statewide crude oil price index has fluctuated more than 5 percent during the life of this project and adjustments to the following Bid Item Number(s) must be made in accordance with Section 9-1.07, "Payment Adjustments for Price Index Fluctuations," of the Standard Specifications:

Item No.	Item Description
Item 1	Item 1 Description
Item 2	Item 2 Description
Item 3	Item 3 Description

Method of Payment:

Payment Adjustment at Agreed Unit Price: $
A cost analysis is on file in the project records.

Time adjustment:

This change order will not affect the controlling activity. No time adjustment is warranted.

Dispute Resolution Advisor (DRA)

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Extra work at force account:
Establish a Dispute Resolution Advisor (DRA) for this contract in accordance with Section 5-1.43, "Potential Claims and Dispute Resolution," and Section 5-1.43E(2), "Dispute Resolution Advisor," of the Standard Specifications.

The Department reimburses the contractor for 1/2 of the invoiced costs to the DRA and 1/2 of the costs of any technical services agreed to. Markups are not added. Payments to the contractor for the Department's share of the DRA costs will paid by force account as provided in Section 9-1.04, "Force Account," of the Standard Specifications.

Estimate of Force Account Work: $

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Establishing a Dispute Resolution Advisor (DRA)

Reason for change:
Section 5-1.43E(2), “Dispute Resolution Advisor,” of the Standard Specifications, applies to a contract with a total bid from $3 million to $10 million.
The DRA is a single-member board established by the Department and contractor to assist in the resolution of disputes.

Method of payment:
The Department reimburses the contractor for 1/2 of the invoiced costs to the DRA and 1/2 of the costs of any technical services agreed to. Markups are not added. Payments to the contractor for the Department's share of the DRA costs will paid by force account as provided in Section 9-1.04, "Force Account," of the Standard Specifications. A cost analysis is on file in the project records.

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Dispute Resolution Board (DRB)

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Extra work at force account:

Establish a Dispute Resolution Board (DRB) for this contract in accordance with Section 5-1.43, “Potential Claims and Dispute Resolution,” and Section 5-1.43E(3), “Dispute Resolution Board,” of the Standard Specifications.

The Department reimburses the contractor for 1/2 of the invoiced costs to the DRB and 1/2 of the costs of any technical services agreed to. Markups are not added. Payments to the contractor for the Department's share of the DRB costs will paid by force account as provided in Section 9-1.04, "Force Account," of the Standard Specifications.

Estimate of Force Account Work: $0.00

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Establishing a Dispute Resolution Board (DRB)

Reason for change:
Section 5-1.43E(3), “Dispute Resolution Board,” of the Standard Specifications, applies to a contract with a total bid of over $10 million. The DRB is a three-member board established by the Department and contractor to assist in the resolution of disputes.

Method of payment:
The Department reimburses the contractor for 1/2 of the invoiced costs to the DRB and 1/2 of the costs of any technical services agreed to. Markups are not added. Payments to the contractor for the Department's share of the DRB costs will paid by force account as provided in Section 9-1.04, "Force Account," of the Standard Specifications. A cost analysis is on file in the project records.

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Federal Trainee Program

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Payment adjustment at agreed unit price:
As part of your equal opportunity affirmative action program, provide on-the-job training to develop full journeymen in the types of trades or job classifications involved. For the Federal training program, the number of trainees or apprentices is [number of trainees], as specified on the Notice to Bidders.

Comply with Section 7-1.11D, “Training,” of the Standard Specifications.

The Department reimburses the contractor 80 cents per hour of training given an employee on this contract under an approved training program:

For on-site training
For off-site training if the apprentice or trainee is currently employed under a federal-aid contract and you do
at least one of the following:
1. Contribute to the cost of the training
2. Provide the instruction to the apprentice or trainee
3. Pay the apprentice's or trainee's wages during the off-site training period.
Estimate of Payment Adjustment at Agreed Unit Price: hours @ $0.80 / hour = $ .00

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Federal Trainee Program

Reason for change:
Section 7-1.11D, "Training," of the Standard Specifications applies if a number of trainees or apprentices is shown on the Notice of Bidders. The number of trainees or apprentices required is [number of trainees].

The Department reimburses the contractor 80 cents per hour of training given an employee on this Contract under an approved training
program.

Method of payment
Estimate of Payment Adjustment at Agreed Unit Price: [number of hours] hours @ $0.80 / hour = [Payment Adjustment]

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Flaggers

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Extra work at agreed unit price:
Furnish flaggers in accordance with Sections 7-1.03, "Public Convenience," and 7-1.04, "Public Safety," of the Standard Specifications.

The contractor must maintain a daily log of flagging labor segregated by individual. A copy of the log and a signed change order bull must be submitted to the resident engineer before the 15th day of each month for payment.

Payment for flaggers and furnish flaggers is as specified in Section 12-1.03, "Construction," of the Standard Specifications and as follows:

In conformance with Section 9-1.04, "Force Account Payment," of the Standard Specifications, the following agreed hourly prices have been determined. These hourly prices represent the Department's 50 percent share of flagging costs. For work performed by a subcontractor, an additional 10 percent markup has been included.

These agreed prices are subject to revision due to any changes in prevailing wage rates or labor surcharge rates. Flaggers (contractor's employees) hours [number of hours] straight time @[hourly rate] /hr.

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Flagging in accordance with section 12-1.03, "Flagging Costs," of the Standard Specifications

Reason for change:
In accordance with Section 12-1.04, “Payment,” of the Standard Specifications, the Department and the contractor will share the cost of furnishing flaggers to provide for passage of traffic through the work as specified in Sections 7-1.03, "Public Convenience," and 7-1.04, "Public Safety," of the Standard Specifications.

Method of payment:
Payment for flaggers and furnish flaggers as extra work under this change order will be made at agreed price unit (hourly) prices.
Hourly costs based on prevailing wage rats with force account markups applied have been determined for laborers and for the contractor's and subcontractor's foremen.

The straight time and overtime rates for foremen include the cost of a pickup truck at the specified equipment rental rate.

In accordance with Section 9-1.04, "Force Account Payment," of the Standard Specifications, an additional 10 percent markup is added to the cost of extra work at force account performed by a subcontractor. The hourly rates shown in the change order for a subcontractor's employees include the additional 10 percent markup.

In case there is a change in prevailing wages or labor surcharges affecting the cost of flaggers and furnish flaggers, a supplemental change order will be written to revise the hourly agreed prices.

Calculations used to determine the agreed unit process are on file in the project records.

Time adjustment:
This change order will not affect the controlling activity; therefore, no time adjustment is warranted.

Item Decrease More Than 25 Percent

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Payment Adjustment at Agreed Lump Sum Price:

In accordance with Section 9-1.06C, "Decreases of More Than 25 Percent," of the Standard Specifications, the adjustment of bid item no. [bid item], [bid item description], that underran the quantity shown on the Bid Item list by more than 25 percent will be $ [adjustment amount].

The Department does not pay more than 75 percent of the item total in the Bid Item List.

Bid Item List Quantity
75% of Bid Item List Quantity
Total Pay Quantity
Total Actual Cost
Actual Unit Cost (Total Actual Cost + Total Pay Quantity)
Bid Unit Price
Amount Paid to Date
Maximum Allowable Compensation (75%of Bid Item Quantity x Bid Unit Price)
Adjustment (Total Actual Cost - Amount Paid to Date)*

*If the Total Actual Cost is more than the Max Allowable Compensation, the adjustment is (Max Allowable Compensation - Amount Paid to Date)

The contractor shall credit the Department a lump sum of $ [lump sum].
This sum constitutes full and complete compensation for this change. There will be no adjustment of time since this change order did not affect the controlling activity.

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Payment adjustment to the unit price for Bid Item No. [bid item number], [bid item description].
In accordance with Section 9-1.06C, “Decreases of More Than 25 Percent,” of the Standard Specifications.

Reason for change:
The total pay quantity for item No. [bid item number], [bid item description] is [percent number] percent of the estimated quantity shown on the Bid Item List due to [reason for change].

In accordance with Section 9-1.06C, “Decreases of More Than 25 Percent,” of the Standard Specifications, if the total item pay quantity is less than 75 percent of the quantity shown on the Bid ItemList, the Engineermayadjust the unit price for the decreased quantity when requested by the contractor.

Method of payment:
Payment Adjustment at Agreed Lump Sum: [lump sum amount].

A cost analysis is on file in the project records. This sum constitutes full and complete compensation, providing all labor,material, equipment, tools, and incidentals, including allmark ups by reason of this change.

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Item Increase More Than 25 Percent

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Payment adjustment at agreed lump sum price:
In accordance with Section 9-1.06B, “Increases of More Than 25 Percent,” of the Standard Specifications, if the total bid item quantity exceeds 125 percent of the quantity shown on the Bid Item List, the Engineer may adjust the unit price for the excess quantity.

The unit price for the quantity of bid item no. [bid item number], [item description], exceeding 125 percent of the quantity shown on the Bid Item List will be adjusted as follows:

The adjustment is the difference between the unit price and the unit cost of the total item pay quantity.
In determining the unit cost, the Engineer excludes the item's fixed costs.

After excluding fixed costs, the Engineer determines the item unit cost under Section 9-1.04, "Force Account," of the Standard Specifications.

Bid Item List Quantity

125% of Bid Item List Quantity

Final Pay Quantity

Quantity Subject to Adjustment (Final Pay Quantity - 125% of Bid Item List Quantity

Total Actual Cost

Actual Unit Cost (Total Actual Cost ÷ Final Pay Quantity)

Bid Price

Difference (Actual Unit Cost - Bid Price)

Adjustment (Quantity Subject to Adjustment × Difference)

The Contractor shall credit the Department a lump sum of $ [lump sum amount]. This sum constitutes full and complete compensation for this change.

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Payment adjustment to the unit price for Bid Item No. [bid item number], [bid item description].

Reason for change:
The final pay quantity for item No. [bid item number], [bid item description] is percent of the estimated quantity shown on the Bid Item List due to [reason for change].

In accordance with Section 9-1.06B, “Increases of More Than 25 Percent,” of the Standard Specifications, if the total bid item quantity exceeds 125 percent of the quantity shown on the Bid Item List, the Engineer may adjust the unit price for the excess quantity.

Method of payment:
Payment Adjustment at Agreed Lump Sum Price: $0.00

A cost analysis is on file in the project records.

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Maintain Traffic

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Perform the following work, as determined necessary by the Engineer:

You will be paid for all resources and activities to complete this work as specified in Section 9-1.04, "Force Account," of the Standard Specifications. Estimate of Extra Work at Force Account $____________ .

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Temporary Traffic Control.
Reason for Change:
In accordance with Section 12, "Temporary Traffic Control," of the Standard Specifications, the following work, when ordered by the Engineer, is change order work.

If ordered, furnish and place additional temporary traffic control devices.
Furnish, install, maintain, move, and remove any additional construction area signs.
Relocate barricades, after initial placement.
Relocate plastic traffic drums, after initial placement.
Lateral move of temporary barrier system, when repositioning is not shown.
Lateral move of temporary barrier system with attached temporary traffic screen, when repositioning is not shown.
Lateral move of temporary crash cushion modules when repositioning is not shown.
Replace or repair of temporary crash cushion modules damaged by traffic.
If ordered, relocate portable flashing beacons after initial placement.
Provide automated flagger assistance device not shown in the Bid Item List.
Place a C23 (CA) (ROAD WORK AHEAD) sign on the entrance ramp within a temporary automated end of queue warning system if not shown.
Provide additional flaggers or advance flaggers if not shown.
Place additional end of queue monitoring and warning with pickup truck mounted changeable message sign (PTMCMS).
Continue monitoring the queue and warning traffic beyond the initial 2 hours after lane closure removal when traffic falls 10 mph or more below the posted speed limit.
If ordered, install a temporary barrier system at all falsework located less than 12 feet from the edge of a traveled way, except at vehicular openings.
Construct a temporary pedestrian access route that is not shown on the Bid Item List.

Method of Payment:
Extra Work at Force Account

You will be paid for all resources and activities to complete this work as specified in Section 9-1.04, “Force Account,” of the Standard Specifications.

A cost analysis is on file in the project records.

Estimate of Extra Work at Force Account work = [$XXXX].

Time Adjustment:

No time adjustment will be made, since the work described in this change order did not result in a critical delay.

Partnering

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Extra work at force account:
Implement project partnering in accordance with Section 5-1.09, "Partnering," of the Standard Specifications. The Department pays the contractor for:

One half of partnering workshops and sessions based on facilitator and workshop site cost.
One half of monthly partnering evaluation survey service cost.
Partnering skills development trainer and training site cost.

The Department determines the costs based on invoice prices minus any available or offered discounts. The Department does not pay markups on these costs.

Estimate of Force Account Work: $ [force account work estimate].

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Partnering workshops and sessions, partnering evaluation survey service, and partnering skills development training.

Reason for change:
Partnering is a way of conducting business in which 2 or more organizations make long-term commitments to achieve mutual goals. This requires changing traditional adversarial relationships into team-based relationships. Partnering promotes open communication among participants, trust, understanding, and teamwork.

Professionally facilitated project partnering and training in partnering skills development are required on all projects with a total bid greater than
$10 million and 100 or more original working days.

Method of payment:
The Department pays the contractor for:

One half of partnering workshops and sessions based on facilitator and workshop site cost.
One half of monthly partnering evaluation survey service cost.
Partnering skills development trainer and training site cost.

The Department determines the costs based on invoice prices minus any available or offered discounts. The Department does not pay markups on these costs.

Payments to the Contractor for the Department's share of the Partnering costs will paid by force account as provided in Section 9-1.04, "Force Account," of the Standard Specifications. A cost analysis is on file in the project records.

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Water Pollution Control Maintenance

Form CEM-4900, Change Order (PDF)

Example for use in the "Description of Work" section:

Extra work at force account:
Maintain temporary soil stabilization measures, temporary sediment control measures, and temporary tracking control measures, as determined necessary by the Engineer. Comply with Section 13.5, "Temporary Soil Stabilization," Section 13.6, "Temporary Sediment Control," and Section 13.7, "Temporary Tracking Control," of the Standard Specifications.

All work shall be done in accordance with the Standard Specifications.

This work will be paid by force account. The cost of labor, materials, and equipment, as approved by the Engineer, will be determined in accordance with the provisions in Section 9-1.04, "Force Account," of the Standard Specifications. The contractor will be paid 1/2 of that cost.

Estimate of Force Account Work: $ [force account work estimate]
This change order will not affect the controlling activity. No time adjustment is warranted.

Form CEM-4903, Change Order Memorandum (PDF)

Example for use in the "This Change Order Provides For" section:

This change order provides for:
Maintenance of temporary soil stabilization measures, temporary sediment control measures, and temporary tracking control measures.

Reason for change:
Section 13.5, "Temporary Soil Stabilization," Section 13.6, "Temporary Sediment Control," and Section 13.7, "Temporary Tracking Control," of the Standard Specifications provide for cost sharing with the contractor for temporary water pollution control practices for protecting storm water systems and receiving waters from the discharge of potential pollutants.

Method of payment:
The Department and the contractor share the cost of maintaining temporary soil stabilization measures, temporary sediment control measures, and temporary tracking control measures. The Department determines the maintenance cost under Section 9-1.04, "Force Account," of the Standard Specifications and pays the contractor 1/2 of that cost.

A cost analysis is on file in the project records. Estimate of Force Account Work: $ [force account work estimate].

Time adjustment:
This change order will not affect the controlling activity. No time adjustment is warranted.

Change Order Templates

Crude Oil Price Adjustment

Dispute Resolution Advisor (DRA)

Dispute Resolution Board (DRB)

Federal Trainee Program

Flaggers

Item Decrease More Than 25 Percent

Item Increase More Than 25 Percent

Maintain Traffic

Partnering

Water Pollution Control Maintenance

Change Order Information

Statewide Campaigns

Statewide Campaigns

Statewide Campaigns

Statewide Campaigns