Exhibit A to DOP Space Process Document

Emory Department of Pediatrics Formal Space Request Form

Please complete all fields in the tables below to the best of your ability.

If you have questions, please contact Liz McCarty (, 2-8226).

TODAY’S DATE
NAME OF REQUESTER
ACADEMIC TITLE
DIVISION or CENTER HOME
NAME OF DIVISION CHIEF WHO SUPPORTS YOUR REQUEST (SIGNED CONCURRENCE FROM YOUR CHIEF MUST BE SUBMITTED WITH THIS REQUEST FORM)
CURRENT SPACE LOCATION/ASSIGNMENT
(Indicate room(s) and bench letter(s) currently occupied including hallways space as indicated by nearest office number)
REQUESTED SPACE ASSIGNMENT
(Indicate additional room(s) and bench letter(s) requested)
NAMES OF INDIVIDUALS WHO WILL OCCUPY NEW SPACE REQUESTED:
NAMES OF INDIVIDUALS DISPLACED IF REQUEST IS HONORED:
DATE NEEDED (If this is for a new hire, indicate date of new hire)
JUSTIFICATION – Describe in a paragraph or less the nature of your request (i.e. prep rooms, benches, etc) and the impetus for the request. If you already have assigned space, please indicate why additional space is needed

Funding Source Table: Identification of funding sources currently available to illustrate your cost recovery

Grant Name and Number / Funding Agency / Total Costs for the Current Grant Year (include directs and indirects for the current budget year only) / Entire Project Period for Funding (include all years of the project) / Special Question for
Clinical/Translational Research Studies
If this grant consists of wet and dry lab space needs (ex, clinical trial that requires specimen processing) please specify the approximate % of budget dollars that will be spent for those wet lab needs

Special Specimen Processing Question: If you are conducting research that involves specimen processing within wet lab space, please specify, per grant and per assay, how many samples you expect to process each month on average and the processing time per sample assay.

Grant Name / Assay Required / Sample # per assay and time length of each assay / # of samples per month expected

Special Core Space Request Form: If your current or requested space assignment includes space that is being used in a core capacity (as defined by being occupied by central equipment and providing centralized services open to and benefiting multiple PI’s), please complete the table below.

Core Name / Specific Equipment / Square feet of space / Current list of users