"Project Request Form"

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Project Request Form
Part I:
Requested Work
(To be submitted to Facilities Management c/o Customer Service Center)
Requester / Point of Contact:
Date: _____________________
Name:
Title:
Signature: _____________________
Phone Number:
Location of Work (building, room, area):
Detailed Description of Work Requested:
(Please provide a detailed description of the work needed; attach a sketch as
necessary to make the requirement clear.)
Justification:
(Please provide a brief justification of need for the work requested. Include factors regarding the urgency of
need which affect the priority that should be applied to the work.)
Approval of Request by Academic Department Chair:
Name:
Title:
Signature: _____________________
Phone Number:
Approval of Request by Academic Dean or Administrative Department Director:
Name:
Title:
Signature: _____________________
Phone Number:
page 1
Project Request Form
Part I:
Requested Work
(To be submitted to Facilities Management c/o Customer Service Center)
Requester / Point of Contact:
Date: _____________________
Name:
Title:
Signature: _____________________
Phone Number:
Location of Work (building, room, area):
Detailed Description of Work Requested:
(Please provide a detailed description of the work needed; attach a sketch as
necessary to make the requirement clear.)
Justification:
(Please provide a brief justification of need for the work requested. Include factors regarding the urgency of
need which affect the priority that should be applied to the work.)
Approval of Request by Academic Department Chair:
Name:
Title:
Signature: _____________________
Phone Number:
Approval of Request by Academic Dean or Administrative Department Director:
Name:
Title:
Signature: _____________________
Phone Number:
page 1
Project Request Form (continued)
Part II
- Cost Estimate and Approvals:
Facilities Management Project Estimate (for budgeting purposes only):
Is the project technically and legally feasible?
Yes: ___ No: ___
Meeting Requested to Clarify Scope of Work?
Yes: ___ No: ___
Cost Estimate:
In House / Local Contract
__________
Construction Contract ____________
Design Costs:
__________
Design Costs:
____________
Labor Hours:
__________
Construction Admin: ____________
Material/Contr. Costs:
__________
Construction:
____________
Contingency:
__________
Contingency:
____________
Total Cost:
__________
Total Costs:
____________
Estimated Construction Time: __________
Recommendation to move project forward?
Yes: ___ No: ___
Director of Facilities Management: ___________________ Date: _____________
Review / Approval of Project Scope by Academic Department Chair:
Name: ____________________
Title: ____________________
Signature: _____________________ Date: ____________
Are funds available for the project from the organizational Dean or Vice President?
Yes ___ No ___;
If yes, cost code: ___________________
Approval by Academic Dean or Administrative Department Director:
Name: ____________________
Title: ____________________
Signature: _____________________ Date: ____________
Approval by organizational Vice President:
Name: ____________________
Title: ____________________
Signature: _____________________ Date: ____________
Approved and Funded by the President’s Council or VP of Finance and Administration:
Funds Source: ____________________________
Confirmation of Approval: Signature: ____________________________ Date: ______________
VP, Finance & Administration
Part III
- Return to Facilities Management for processing
Facilities Management Project Information:
Project Number Assigned: _____________; Cost Code Assigned: _________________________
Estimated Project Schedule:
Design Start: __________
Design Complete: ____________
Construction Start: _________
Construction Complete: ____________
page 2
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