Questions on the need to use this form? Email paul.scanlon@sru.edu at the SRU Sustainability Office!
LAND USE PROJECT REQUEST FORM
SLIPPERY ROCK UNIVERSITY
Requested by (Name)
Department/Budget Unit/Sponsor (Name)
College/Division (Name)
Title of Requester
Fund
Fund Center
Telephone Number
SECTION I - PROJECT INITIATION REQUEST
PROJECT TITLE: _________________________________
A.
Purpose of Request (check all applicable categories)
Permanent Change in Use of Land
Remove, Replace, or add Trees/Vegetation
Temporary Use of Land
Install Permanent Structures, Signage, Paths,
Walks, Roadways, Lighting, Trash Receptacles, etc.
Install Temporary Structures, Signage, etc.
Please provide the following information as appropriate, and attach campus map with affected land area
outlined (please note environmentally sensitive areas on campus grounds map):
1.
2.
3.
4.
5.
6.
7.
8.
9.
Land/Lot/Property Name
Map Coordinates of Land
or Mark up attached campus map
Current Area (acres)
Proposed Area(acres)
Current Land Use
ProposedLand
LandUse
Use
Proposed
Proposed Land Use Project Cost
Source of Funds:
Proposed Land Use Annual Maintenance Costs
Source of Funds:
Will any vertebrate animals be used for educational or research purposes?
NOTE: If “Yes”, SRU’s IACUC (Institutional Animals Care and Use Committee) approval is required
BEFORE a Land Use Request Form will be reviewed. Go to IACUC’s website
http://www.sru.edu/academics/colleges/ches/pages/iacuc.aspx for further information and to obtain
the protocol form to be completed. IACUC review/approval process takes approximately 30 days.
10. Will any animals be involved for non-educational/research purpose?
Note: If “Yes”, please attach documentation verifying the animal provider is a licensed vendor
complying with all Animal Welfare Act and other federal requirements.
11. Will this land use require any legal agreements with outside entities?
If “Yes”, attach draft legal agreement including any public liability insurance requirements.
B.
Description of Project
The Department Head/Budget Unit Head/Student Organization Sponsor is responsible for providing a
brief description of the project/proposal. Show how the changes/additions will assist the organization to
better serve the intended audience (e.g., students, faculty, staff, community). Include any needs assessment
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data supporting the request. Clearly state changes desired including any changes to existing structures,
signage, trees, plantings, waterways, etc. Include a copy of the Campus Grounds Map, with the proposed
land use area outlined on it, and all supporting documents with this form, including a description of any
potential impacts of the proposed land use (number of participants/spectators per event, number of events
per year, types of vehicles in use, if any, etc.):
SECTION I – PROJECT INITIATION REQUEST APPROVAL
NAME
E-MAIL ADDRESS
Department/Budget Unit Head/Student Organization Sponsor
SECTION II - PROJECT EVALUATION/IMPLEMENTATION APPROVALS
When you have completed the form, please save it as a document to your hard drive or diskette, naming it
appropriately. You may then e-mail the document as an attached file to paul.scanlon@sru.edu. Please DO
NOT embed the document into the body of your e-mail. Additional supporting documentation can also be
attached to this e-mail if it is in electronic format (on your computer somewhere). Your request will be reviewed
and forwarded to the appropriate University organizations for their recommendation. If any of these materials
(request form and/or supporting documents) are only available in hard copy, forward them to the Paul Scanlon of
the Sustainability Office (currently at the Maintenance Center) by campus mail.
You will be notified by e-mail as to the disposition of your request. Please note that, if this land use request is
approved and the project includes construction involving SRU maintenance crews or outside contractors, a separate
Space/Project Request Form must be used to obtain review/approval of the construction specifics.
SECTION III – PROJECT EVALUATION and/or IMPLEMENTATION APPROVALS
The President may solicit recommendations from the following groups or others, as appropriate:
Facilities & Planning
NAME
Scott Albert
Dallas Cott
Environmental Zoning Committee
NAME
Jerry Chmielewski
President’s Commission
On Disability Issues
NAME
Scott Albert
President’s Commission
On Sustainability
NAME
Herb Carlson
IACUC
NAME
Simon Beeching
EH&S
NAME
Paul Novak
APPROVED BY:
NAME
______________________
E-MAIL ADDRESS
scott.albert@sru.edu
dallas.cott@sru.edu
PHONE
x 4342
x
E-MAIL ADDRESS
jerry.chmielewski@sru.edu
PHONE
x 2489
E-MAIL ADDRESS
scott.albert@sru.edu
PHONE
x 4342
E-MAIL ADDRESS
herbert.carlson@sru.edu
PHONE
x 2545
E-MAIL ADDRESS
simon.beeching@sru.edu
E-MAIL ADDRESS
paul.novak@sru.edu
PHONE
x 2479
PHONE
x 2465
E-MAIL ADDRESS
PHONE
cheryl.norton@sru.edu
724.738.2000
President Cheryl Norton
This document uses the Garamond font to save ink and paper; please print on both sides of paper if hard copies are needed!
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CAMPUS GROUNDS MAP – ENVIRONMENTALLY SENSITIVE AREAS
Land Use Project Request Form
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