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Institutes Affiliated with HOSPITALS - CFI Research EQUIPMENT & space:

NEEDS ASSESSMENT Form

Please complete, obtain signaturesand return copies to: (1)the OSR ISI teamand (2) Christian Ilantzis in the Faculty “Research” office; and to your Hospital/Institute Technical Services contact*.

NAME:
DEPARTMENT/SCHOOL/CENTRE:
PHONE: / FAX:
E-MAIL:
DATE:
Project Number
Project Title
Maximum total Project Cost:
Location (building & room number):
Total sq. ft. required (estimate):
Total number of people to be accommodated (researchers, technicians, other):

Type of space (select one or more):

Wet

Dry

Microbiological

Chemical

Radiochemical

Please complete forAllSPACES:

Specific Requirements (check all applicable and give details as appropriate):

Supply Details
High performance computers
Special temp/humidity/dust requirements
Special lighting requirements
Special power requirements (e.g., cooling required?)
Sound/vibration concerns
Back-up power
Shielding
Heavy loading on floors
Health/safety issues
Security requirements
Accessibility considerations
Human subjects
Animals: Specify species, numbers, surgery requirements
housing level required
Lasers
Autoclave(s) – Specify Number:
Additional considerations

Please complete for allWet lab SPACES:

1) Services Required: / Give details as appropriate
Natural gas
Compressed air
Vacuum lines
Laboratory gases
2) Specific Requirements / Give numbers or quantity as appropriate
Fume hoods
Biological safety cabinets
Chemical storage – Check all applicable and provide quantities if available.
Flammable Liquids
Acids
Bases
Oxidizers
Explosives
Reactive chemicals
Biosafety -- Specify level of biosafety hazard
Radiation -- Specify type of radiation or isotopes
Comments, Additional requirements, specify
Based on the described requirements, do you foresee a need for renovations for your CFI project?
yes no Please give details

I hereby confirm that the space specified herein is suitable for the intended activity, has been reserved specifically for the specified CFI project and will remain so for the five-year duration of said project – Note that for CFI funded renovations the five year period starts from the date of acquisition and installation of the research infrastructure, including all CFI-funded equipment.

•______

Department Chair (Date)

•______

Institute Director (Date)

*Please consult with your Hospital/Institute Technical Services contact for help in completing this form and be sure to provide them with a completed and duly signed copy.Your Technical Services contact can verify (with the aid of this form) whether renovations are needed or not and if needed, can help you obtain the necessary estimate.

The Technical Services contact person for the Douglas Institute’s Research Centre is:

Ronald Sehn

Directeur des services techniques

Direction des services techniques et de l'immobilier

Pavillon Dobell [B-0112]

6875 boul. LaSalle,

Montréal (Québec) H4H 1R3

T: 514 761-6131, poste: 2713

B: 514 567-3313

F: 514 762-3038

The Technical Services contact persons for the Jewish General Hospitalare:

Georges Bendavid
Directeur adjoint - services techniques
Tel : (514) 340-8222 Ext 3962

James Shapiro
Chef, Secteur Maintenance
Services techniques
Tel: (514) 340-8222 Ext. 5870

The Technical Services contact person for the MUHC is:

Susan James, MBA
CFI Project Manager
Ext. 71562

Research equipment & Space needs assessment form (November 2014 version)13-Dec-18