How do I report on revocations?

OKay, I am on VIA 6.9.1. I want to write a report on Access Revocation Requests.

What I mean is that we have an access request form and when somebody choses remove either on a group, entitlement, etc, we want to then later report on it.

We want to report by timeframe. Between start and end. We want all the change request numbers, the user logins, the entitlement or group that requested to remove, when it was requested and when it was completed if it was.

Change                 User                                                                                                      Date                   Date
Request #           Account Name                  Entitlement                                        Requested          Completed     

1234                       Rick Byers                            ap-uu-p-pacm-xxx                          4/1/2016              4/2/2016             
1234                       Paul Duer                            ap-uu-p-pacm-xxx                          4/1/2016              4/2/2016