Product Change Request Form
KROGER CO.
Kroger Tracking Number:
Section A. Change Request
To be completed by Supplier and submitted to either [email protected] or [email protected]
Steps 1-11 are to be completed at original change request submission.
Step 1. Supplier Identification
Complete Information below.
Supplier Company Name:
Supplier Identifier:
Street Address:
City / State / Province:
Country:
Zip Code:
Step 2. Supplier Change Assessment Checklist
Check all that apply.
In order to enable Kroger to determine if any proposed change to supplier product(s) or service(s) will have any effect
on the safety and/or efficacy of any Kroger product(s), supplier is hereby notifying Kroger in writing prior to making a
change in the following aspects of the product(s):
Raw Material Change (Composition)
Design Change
Raw Material Change (Source)
Change in Labeling and Packaging
Raw Material Discontinuation
Change in subcontractors for distribution, producing,
processing or testing
Change in Method / Equipment of manufacturing,
producing, processing, or testing
Other. If other, describe below:
Physical Change in Location or address – Please
indicate new location where new change will
occur:
Supplier Name Change
Operating under SAME Quality System
NEW Quality System
“Other” Description:
Step 3. Kroger Part Number(s)
Enter applicable Kroger Part Numbers or attach list.
KLN Number(s):
See Attached
Step 4. Kroger UPC
Enter if applicable or attach list.
Kroger UPC:
See Attached
Step 5. Description
Enter if applicable or attach list.
List Product Name(s):
See Attached
Page 1 of 4
FORM NO.:
REVISION:
OWNER:
Global Sourcing
Kroger Co. - INTERNAL USE ONLY
ISSUE DATE:
EFFECTIVE DATE:
VPRC001
1
March 1, 2015
March 1, 2015
Product Change Request Form
Kroger Tracking Number :
Step 6. Kroger Manufacturing Facilities
Enter all that apply or attach list.
Indicate all facilities that are supported:
Step 7. Category Desk Contact
See Attached
Enter all that apply or attach list.
Identify Sourcing Manager Contact:
See Attached
Step 8. Corporate Food Technology Contact
Enter all that apply or attach list.
Identify Contact:
See Attached
Step 9. Packaging Engineering Contact
Enter all that apply or attach list.
Identify Contact:
See Attached
Step 10. Requested Date of Change
Enter the date the supplier is targeting to implement the change.
Suppliers must receive Kroger approval, via this approved form,
prior to shipping impacted materials to Kroger facilities for production use & release.
NOTE: Change proposal form SHALL be submitted to Kroger Co. at a minimum of 120 days prior to change going into
effect. If change request is received after the 120 day deadline change proposal request is at risk of denial.
Step 11. Proposed Change
Enter description of proposed change(s).
Description of Change:
Step 12. Reason for Change


Explain why changes are being proposed.
Provide rationale, when appropriate, for why the change is appropriate, justified, or needed. (Explain why it is
acceptable to make the proposed changes.)
Reason for Change:
See Attached Data
Is the product or process change request a result of actions:



Information not available
to reduce customer complaints or to respond to a customer complaint?
to respond to an FDA or other regulatory request?
to achieve cost savings (in raw materials, components, process, other)?
If “Yes” selected above, explain here:
Yes
Yes
Yes
No
No
No
If yes, please
describe
details below.
See Attached Data
Page 2 of 4
FORM NO.:
REVISION:
OWNER:
Global Sourcing
Kroger Co. - INTERNAL USE ONLY
ISSUE DATE:
EFFECTIVE DATE:
VPRC001
1
March 1, 2015
March 1, 2015
Product Change Request Form
Kroger Tracking Number :
Step 13. Disposition
Accept Change
To be completed by Kroger Global Sourcing Manager.
Reject Change
Additional Information
Administrative Closure
Enter any additional information or comments.
Information or comments:
N/A
Supplier Change Proposal Decision?
Accepted
Rejected
Included Facilities or parts:
This approval indicates that the Requirements have meet Kroger Co internal quality management requirements
Global Sourcing Manager Name (Print)
Date
Page 3 of 4
FORM NO.:
REVISION:
OWNER:
Global Sourcing
Kroger Co. - INTERNAL USE ONLY
ISSUE DATE:
EFFECTIVE DATE:
VPRC001
1
March 1, 2015
March 1, 2015
Product Change Request Form
Kroger Tracking Number :
Reference Only
Step . Recommended Supplier Supporting Data



Check box when data from Step 9 is attached.
Based on the type of SNC being submitted, the data indicated below is requested to be submitted with the SNC.
For suppliers who maintain Packaging/Labeling and/or specifications, which are under Kroger Co Design Control,
provide a copy of the updated drawings and/or specifications with the SNC.
For SNCs that do not belong to one of the below categories, the supporting data may be individually determined by
the Project Leader, once assigned.
Supporting
Requirements
Raw Material Change
(Composition)
Raw Material Change
(Source)
Change in Method /
Equipment of
manufacturing,
producing, processing,
or testing
Design Change
Physical Change in
Location or address
Change in
subcontractors for
distribution, producing,
processing or testing
Mold repair,
refurbishment or
modification 2
Specification
compatibility,
comparison,
gap analysis
Supplier
Validation,
verification,
commissioning
report 1
Safety &
regulatory
review
Y
Y
Y
Y
Mold
approval
Supplier
declaration of no
change to:
design, material,
process, or
testing
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FORM NO.:
REVISION:
Global Sourcing
Y
Y
Page 4 of 4
OWNER:
Supplier
own
assessment
report
Kroger Co. - INTERNAL USE ONLY
ISSUE DATE:
EFFECTIVE DATE:
VPRC001
1
March 1, 2015
March 1, 2015