Request for Research Space
Name
Email Address
Phone Number
Principal Investigator
Lab Contact or Manager
Division Administrator
PI Department/Division
Briefly describe the area of research:
SPACE REQUEST
Is the request for new or an addition to currently assigned space?
New Space
Additional Space
Is the requested space to support a new extramurally funded research study?
Yes
No
Please note faculty member's level of protected research time (e.g., 50%, 75%, etc.)
What type of space is being requested (please select all that apply)?
Wet Lab
Dry Lab
Faculty Office
Does the investigator currently have space on the CHLA Campus? (outside of Saban or SRT)
Yes
No
If investigator currently has assigned space, please specify location and approximate square footage:
Is the investigator losing space in the hospital or anywhere on campus?
Yes
No
If yes, please elaborate
Approximately how many square feet of space is being requesting?
What is the anticipated use of the space (describe your anticipated research activities)?
How soon will the additional space be needed (please provide specific dates, if known)?
How long will the space be needed?
Please list all individuals who will need access to the requested space:
Name
Employee Type (e.g. Volunteer, Postdoc, etc.)
FTE
Designated remote or onsite
Will patients patients be seen in this space?
Yes
No
If yes, please describe the use of patient space:
Will staff be making a high volume of phone calls? If yes, please elaborate on types of phone calls.
What percentage of time would staff be utilizing the requested space? Please elaborate by writing days and hours of the week.
Do all staff members work the same schedules or do they vary?
If employees are designated as onsite, are there options for them to occasionally work from home?
Yes
No
If yes, how often can they work from home?
EQUIPMENT, FURNITURE AND MATERIALS
Will office furniture be required?
Yes
No
Maybe
If yes, please provide details below (i.e., number of desks, chairs, etc.)
Will patient records need to be stored in the requested space?
Yes
No
If yes, is offsite storage an option?
Yes
No
Will the investigator have equipment or materials they will be bringing?
Yes
No
If yes, select all that apply:
Frozen samples
Lab chemicals
Biohazardous materials
Please add items below:
If you have specialized equipment, please specify below:
INFORMATION SERVICES
There are specific IS needs? (e.g. additional data ports, etc.)
Yes
No
If yes, please provide details below.
Please upload your CV here
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