DEPARTMENT OF HEALTH AND HUMAN SERVICES Space Design ...
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PROGRAM SUPPORT CENTER
SPACE REQUEST FORM
Email: space@
REQUESTING OPDIV/STAFFDIV
TODAY¡¯S DATE (mm/dd/yyyy)
POINT OF CONTACT¡¯S NAME AND TITLE
EMAIL ADDRESS
PHONE NUMBER
LOCATIONS
National Capitol Regions (NCR) (Select one)
Regional Offices (Select one)
TYPE OF REQUEST (Select one)
New Space Request (Check)
Release of Space Request (Check)
_____Number of Existing Staff ( _____ FTEs _____ Contractors)
_____Square Footage/ Room Number
_____Number of New Staff ( ______ FTEs _____Contractors)
__________ Estimated Space Release Date (mm/dd/yyyy)
(Contingent upon reassignment of space)
_____Number of Workstations Needed
Needs Project Management Support
_____Number of Offices Needed
_____________ Project Management Support
Completion Date (mm/dd/yyyy)
_____Conference Rooms and Collaborative Spaces
Complies with the 21st Century Workplace Space
Planning Policy
Alterations Request to Existing Space (Check)
_____Existing Workstations
_____Alteration to Existing Offices
_____Other Services (move, signage, AV, IT, Telecom, etc.)
_____Furniture Design
Reasonable Accommodation is Required
DESCRIPTION OF SPACE, ALTERATIONS, RELEASE REQUEST (Briefly summarize requirements for proposed and for further explanation
provide it in the email).
FUNDING (Briefly describe the funding source that is available. Work cannot begin until funds are certified.) (Select One)
Credit Card
Requisition (Supplier Site)
Agreement (7600, SLA, IAA)
CAN Number
DESCRIPTION OF FUNDING (Briefly summarize and for further explanation provide it in the email.)
AUTHORIZING OFFICIAL
The person below is responsible for authorizing the activities, scope of work, and making financial decisions.
NAME
TITLE
EMAIL ADDRESS
PHONE NUMBER
AUTHORIZING OFFICIAL SIGNATURE
DATE (mm/dd/yyyy) SECONDARY SIGNATURE
ASFR CONCURRENCE IF APPLICABLE
DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)
NOTE
?
Your request is subject to analysis of existing space conditions.
?
A more detailed Program of Requirements (POR) may be required.
?
A final space decision will be made by senior leadership.
FOR INTERNAL PSC USE ONLY
DATE RECEIVED (mm/dd/yyyy)
PROJECT NUMBER
PSC-173 (12/23)
DATE ASSIGNED (mm/dd/yyyy)
NAME OF PROJECT MANAGER
DATE PROJECT REQUEST REVIEWED WITH CUSTOMER (mm/dd/yyyy)
PSC Publishing Services (301) 443-6740
EF
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