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Department of Medicine Research Space Request Form

If your Division Chief is unable to provide you with space, please use this form to request additional research space (laboratory, shared, storage, office) from the Department of Medicine. Please note that the Department of Medicine makes no guarantee of additional space.

This request must be submitted two months prior to the relevant submission deadline. Do not wait until you are certain of funding to make the request. If you are unclear on any aspect of the research space policy please read it now. You will be required to indicate that you have reviewed it before submitting your request.

All fields are required.

*Name:

*Address:

*Phone (XXX-XXX-XXXX):

*Email:

*Division:

*Request date:

*Submission deadline:

*Anticipated funding start date:

*Current research space:

*Current funding (include program year DC and IDC for each funding source):

*Pending funding (include program year DC and IDC for each funding source):

*Details of request for additional space:

*Justification for request (anticipated grant, funding, and staff):

*Divisional constraints:

*Division chief name:

*Division chief e-mail address:

* I have read and understood the Department of Medicine research space policy.

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