4700 R
esearch Way Lakeland FL 33805-8531 864-874-8593
Project Budget:
Source of Funds (Chartfield):
Reason for Request (please provide details e.g. type of equipment (model #), electric, plumbing or ventilation required, etc.)
Date:
Requestor:
Phone:
Supervisor's Signature:
Email:
SIGNATURES BELOW ARE REQUIRED PRIOR TO MOVING FORWARD WITH THE SPACE IMPACT
Dept Head/Chair (please print)
Vice President (please print)
Signature:
Signature:
Date:
Phone:
Phone:
Date:
STEP 1: TO BE COMPLETED BY REQUESTOR
STEP 3: TO BE COMPLETED BY APPROVER
Space Impact Request
Facilities and Safety Services
Please return completed form to: safetyservices@floridapoly.edu
Code Reviewer:
Remarks:
Facilities Reviewer:
Date:
Date:
Remarks:
RESULT OF REVIEW
Approved:
Approved:
Estimated Cost:
Request Granted:
Request Denied:
STEP 2: TO BE COMPLETED BY REVIEWER
REV 2019.10.30
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4700 Research Way Lakeland FL 33805-8531 864-874-8593
SPACE IMPACT REQUEST FORM
INSTRUCTIONS
The goal here is to indicate overall, long-term implications of a project, especially those regarding three main issues:
(1) Will it change the inventory classifications of rooms (e.g. classrooms to offices or teaching labs to research labs)?
(2) Will it change the numbers of rooms by dividing individual rooms into separate ones or by combining rooms?
(3) Will it alter the “budget entity” that is using any of the spaces involved (for example, from E&G to C&G or AUX)?
Technical details will become relevant later, when and if the project is implemented (e.g. air conditioning, lighting,
electrical wiring, etc.). By contrast, what should be outlined now is only enough information to clarify the project and
allow a determination of answers to questions like those mentioned.
Requester is to complete Step 1 of the Form and email the completed form to their immediate supervisor. After
approval by supervisor please submit the completed and signed form to safetyservices@floridapoly.edu. Step 2 will be
conducted by Code Reviewer and Facilities Reviewer for compliance and constructability. Once reviewed the Form will
be sent back to the Requester to complete Step 3.
Once all signatures and information identified in Step 3 are obtained, please submit the completed Space Impact Form
to: safetyservices@floridapoly.edu.