Request for Research Space

Please note this space request for is for Saban and SRT only. This form is used in accordance with the Research Space Assignment Guidelines. If you need to submit a space request outside of Saban and SRT, please use the Campus Planning and Construction Space Request Form.

	Name	Email Address	Phone Number
Principal Investigator
Lab Contact or Manager
Division Administrator
Division Chief

PI Department/Division *

If there is more than one Principal Investigator requesting space, please complete this section:

	Name	Email Address	Phone Number
Principal Investigator
Lab Contact or Manager
Division Administrator
Division Chief

PI Department/Division

Briefly describe the area of research: *

SPACE REQUEST

Is the request for new or an addition to currently assigned space?*

New SpaceAdditional SpaceTemporary SpaceExtension of Temporary Space

What type of space is being requested (please select all that apply)?*

Wet LabDry LabFaculty OfficeOther

Approximately how many square feet of space is being requested?*

What is the anticipated use of the space? (describe anticipated research activities)*

How soon will the space be needed (please provide specific dates, if known)? *

How long will the space be needed? (If temporary, please provide specific dates)*

Please list all individuals who will need access to the requested space (including any positions you may be hiring for):

	Name	Employee Type (e.g. Volunteer, Postdoc, etc.)	FTE	Designated remote or onsite

Will patients be seen in this space?*

YesNo

If Yes, please describe the use of patient space: *

Will staff be making a high volume of calls in this space?*

YesNo

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?

YesNo

If Yes, how often can they work from home?

Does the investigator currently have research space on the CHLA campus? (outside of Saban or SRT)*

YesNo

If Yes, please describe current space (location, square footage, etc.) *

Is the investigator losing space in the hospital or anywhere on campus?*

YesNo

If Yes, why is the space being lost? Please elaborate below.*

RESEARCH AND FUNDING

Please note faculty member's level of protected research time (e.g., 50%, 75%, etc.) *

Is the requested space to support a new extramurally funded research study?*

YesNo

If Yes, please provide funding information below:

	Funding Agency	Funding Start Date	Funding End Date	What type of research grant (multi-site, multi-PI, etc.)	Are you the PI or site PI for this grant? If no, list PI	Your % effort on this grant
-
-
-
-
-

If Yes, please attach the Notice of Award (NOA)

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Was this indicated on the Grant Intake Form?*

YesNo

Please attach copy of Grant Intake Form here

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Please attach the PI’s Other Support document here

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Has this research space request been discussed with the Division Chief?*

YesNo

Please upload CV here *

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EQUIPMENT, FURNITURE AND MATERIALS

Will office furniture be required?*

YesNoMaybe

If yes, please provide details below (i.e., number of desks, chairs, etc.)

Will patient records need to be stored in the requested space?*

YesNo

If yes, is offsite storage an option?

YesNo

Will the investigator have equipment or materials they will be bringing?*

YesNo

If yes, select all that apply:

Frozen samplesLab chemicalsBiohazardous materials

Please add items below:

If you have specialized equipment, please specify below:

INFORMATION SERVICES

Are there any specific IS needs with this request? (e.g. additional data ports, etc.)*

YesNo

If yes, please provide details below.