ASC Procedure Room Request

For dedicated use over extended period to be renewed every 6 months.

Name of PI*
First Last
Research Lab Location*
Affiliation*
- BUMC
- BU CRC
- BMC
- Other
Affiliation (Other)
Contact Phone*
Contact Email*
Address*
Dates Requested

Subject to availability, dedicated procedural space will be granted for up to six months and extended in six-month increments with justification and/or co-sharing or other arrangements.
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Research Activity
BU IACUC Protocol Title*
BU IACUC Protocol Number*
Species*

Research Equipment

Equipment	Dimensions

List proposed research activities to be performed in the room.*
Do you need to make any modifications to the room (e.g., special requirements for equipment)?*
All modifications will need ASC approval and should be removed by PI at the end of the term.
List your lab members and research activities they will be performing in the room.*

Dates Requested