SPACE REQUEST SCREENING FORM
University of Wisconsin-Stout
Completion of the Space Request Screening Form is phase one in the Space Request Process. The
information supplied in this form enables the Space Allocation Committee to determine whether the
requested space change is feasible and can move to the analysis phase. If approved, phase two of the
process requires the requestor to provide additional detailed information by completing the Space
Request–Short Form for final approval of the space change.
1. Requestor Information
Name:
Date:
Campus Phone:
Campus Email:
College/Unit:
School/Department:
2. Justification
Briefly describe why this space is needed:
Is this space:
New
or
Existing
Select what function the space will serve (check all that apply):
Office
Clinical
Storage
Research
Designated Classroom
Other (describe)
Classroom Laboratory
Gen’l Access Classroom
___________________
Open Laboratory
Other Instructional (describe) ____________________
______________________________________________
How will the use of this space align with UW-Stout’s strategic, capital or unit plan?
Describe why the existing space cannot accommodate this need:
Will existing space be vacated if other space is acquired?
If Yes: A) Location of vacated space:
B) Square footage of vacated space:
Yes
No
_______________________________
_______________________________
3. Features
Select features that will be required (select all that apply):
Power Requirements
Voltage:_______________
Special Outlets
Exhaust
Fume Hoods
Dust Collection
Vibration Isolation
Water
Lab Gas
Sinks
Natural Gas
Drainage
Steam
Telephone
Chilled Water
Data/Internet Connection
Wide / Tall Doorways
Compressed Air
Structural Support
Other:_______________________________________
4. Utilization
Indicate the type and approximate number of users of the space (check all that apply):
Type of User:
Number of Users per Week:
Students:
Faculty/Staff:
Public:
Other _________
Other _________
_______________________
_______________________
_______________________
_______________________
_______________________
What approximate times of day will this space be utilized?
Mondays:
________________________________
Tuesdays:
________________________________
Wednesdays:
________________________________
Thursdays:
________________________________
Fridays:
________________________________
Saturdays:
________________________________
Sundays:
________________________________
Do you need the space:
temporarily OR
permanently
If Temporary: How long will you use the space? ______________________________________
What accommodations are needed to share this space with other users?
5. Funding
How much funding has been identified by your department or unit to support modifications and
maintenance of the space?
________________________
Additional Information:
6. Ideally, when is the spaced needed? ______________________________________________
(Allow a minimum of twelve months for space requiring remodeling )
Explain:
7.
What will the impact be if this space request is not approved?
Explain:
8.
Route for Signature Approval:
Recommended for Approval to proceed
to Analysis Phase:
Not Recommended for Approval:
Reviewer
Department Chair /
Immediate Supervisor
Dean / Unit Director
Division Administrator
Space Committee Chair
Explanation:
Chancellor
RETURN TO REQUESTOR
If approved, complete Space Request Form to continue the process located at:
https://www.uwstout.edu/admin/asls/intranet/forms.cfm