Qualtrics Survey | Qualtrics Experience Management

Requestor's Contact Information

Department/Program:

Contact Person:

Date Submitted (mm/dd/yyyy):

Phone Number:

Email Address:

1. Describe in detail the amount and type of space being requested and the functions that will be performed in the space. Please include any other information that is important/relevant to SRAAC’s review, including the change in circumstances that is prompting this space request.

2. Is this retention of space or a request for new space?

Retention of Current Space
Request for New Space

3. Provide a justification for the amount and type of space requested.

4a. List funding and Award Synopsis for each grant cited on the request. Format (# of years, Naming agency, Date Range, Direct Costs).

4b. In support of Question 4a, attach copy of Funding and Award Synopsis here.

5a. Include a list of personnel, shown by title, who will need to be accommodated in the requested space. Format (Employee Type [research, faculty, etc], Name, Starting Date)

5b. In Support of Question 5a, attach copy of personnel list with details here.

6a. Please provide a location of current space allocated to requestor as well as square footage.

6b. In Support of Question 6a, attach floor plan or current space inventory here.

7. Please include memorandum of support for the space request from the Department Chair, including their letterhead and Signature (.PDF or .DOC).

8. Chair Signature: Sign below in attestation that the information provided is accurate.

Sign Here

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