NUHS Research Space Request Form (Clinical Research Space) (Updated 02March 2016)

NUHS Research Space Request Form (Clinical Research Space) (Updated 02March 2016)

NUHS Research Office

NUHS Research Space Request Form (Clinical Research Space)(Updated 02March 2016)

For Official Use
Date Received
Application No.

Name of Applicant:______

Staff ID: ______

Department:______

A. Space Request

For Official Use
Indicator / Nos. needed / Preferred Location
(Building/ Level/Room) / Duration of Occupancy: (Start/End Date; Month/Year) / Space Approved
(Gross Floor Area in m2)
Consultation Room 1 / Yes / No
Procedure Room 2 / Yes / No
Interview Room 3 / Yes / No
Workstation/ Hot-desk 4 / Yes / No
Storage space / Yes / No

1 Furnished with Basin, Workstation and office chairs, Examination Couch

2 Furnished with Basin, Table and office chairs

3Furnished with Round table and office chairs

4 Furnished with Hot-desk station/Workstation and office chair

For Official Use
Details / Justifications / Remarks
Space Requested
(Specify as indicated above)
Reason(s)/ Proposed use
Personnel using space requested
(Incl all full/ part-time staff)
Equipment to be placed in space requested
(Incl measurements)
Special requirements needed/ for consideration / Eg. Prefer adjacent to (area) for (reason); Need 32 Amp power supply for (equipment)

B. Details of Current Departmental/Central Research Space

For Official Use
Clinical Space Type / Building
(e.g. MC, Main Building, IMU) / Level / Room No. / Current Space
(Gross Floor Area in m2)

C. Active Grants Applicable to Space Request

i. Grants Awarded to Applicant as Principal Investigator5

Type of Grant
(BMRC, NMRC, NRF etc.) / Finance Account
(WBS / Internal Order) / Amount Awarded (S$) / Grant Duration
(Start/End Date) / Space has previously been awarded under this grant
(Yes/No)

5Applicant must at least hold one grant as Principal Investigator

ii.Grants Awarded to Applicant as Co-Investigator/Collaborator6

Type of Grant
(BMRC, NMRC, NRF etc.) / Finance Account
(WBS / Internal Order) / Amount Awarded to PI (S$) / Amount Dedicated to Co-I (S$) / Grant Duration
(Start/End Date) / Space has previously been awarded under this grant
(Yes/No)

6Co-investigator/Collaborator is required to seek endorsement fromthe Principal Investigatorof grant

(Section F, Part i) before the grant can be consideredinthe application of clinical research space

D. Staff Occupancy

(Applicable only if requesting for Workstation/ Hot-desk)

Building
(e.g. MC, Main Building, IMU) / Level / Room / Number of Research Staff / For Official Use
Space Required
(Gross Floor Area in m2)
Current Staff:
New Staff:
(To be Recruited)

E. Details of Current & NewResearch Staff

(Applicable only if requesting for Workstation/ Hot-desk)

For Official Use
Name / Status
(Current/New) / Staff No. / Designation
Research Fellow (RF), Research Assistant (RA),
Clinical Research Coordinator (CRC) / Staff Verification

NB.Please added rows accordingly where necessary

F. Signatories

i. Endorsement by Principal Investigator7

(To be completed by Principal Investigator of grants listed in Section C, Part ii)

Finance (WBS/ Internal Order) No. of Grant: / Principal Investigator:
% Research Space for Applicant/
Co-Investigator/Collaborator: / %
Signature/Date
Finance (WBS/ Internal Order) No. of Grant: / Principal Investigator:
% Research Space for Applicant/
Co-Investigator/Collaborator: / %
Signature/Date
Finance (WBS/ Internal Order) No. of Grant: / Principal Investigator:
% Research Space for Applicant/
Co-Investigator/Collaborator: / %
Signature/Date

7Principal Investigator is required to state any existing research space reserved for the applicant/co-investigator/ collaborator based on his/her contribution in the research project of the grant

ii. Endorsement by Head of Department

In signing the NUHS Research Space Request Form, the Head of Department,

  • declares that he/she has considered the research space application and is unable to provide departmental research space for the applicant,
  • supports the applicant’s request for central research space.

Head of Department:______

Name Signature/Date

iii. Declaration by Applicant

I hereby declare that all the information provided above is true and complete. I understand that any false information or deliberate omissions on this document could lead to disqualification and retraction of allocated research space.

Applicant:______

Name/Designation Signature/Date

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