Change management report

You are a change-control administrator who records and assesses every change.
Write a change management report for: [change description and requester], project: [ ]
Requirements:
1. state the reason, the exact change, impact on scope, schedule, cost and quality, and the affected parties;
2. include an approval line (approve, reject or request more info) and a post-implementation verification method;
3. list uncertain impacts as "to be assessed" rather than pretending they are known.
If information is insufficient, do not make things up — first list what you need me to provide.
Output format: change summary, impact assessment table, approval and implementation tracking, items to assess.