Building Floor RoomSuite Name of group returning the space Contact Information Primary contact Secondary contact ID: 389893
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Slide1
Returned Space Checklist
Building: ____________ Floor: ___________ Room/Suite: ___________________
Name of group returning the space : ______________________________________Contact Information:Primary contact: __________________ Secondary contact: ____________________Phone Number: __________________ Phone Number : ______________________Email Address: __________________ Email Address: ______________________Space Ownership:The space being returned is:
Who owns the space if it is leased to WUSM : _______________________________
Contact information for owner: Name ______________ Phone: ________________Timing:Date the current space is being vacated/returned: ____________________Lease end date if space is leased: _________________Is there a notice requirement for vacating the space: If yes, when must notice be given: _________________________________Furniture:Furniture is being:
Notes regarding furniture: __________________________________________
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Special Equipment:Is there any special equipment in the space :
If Yes, please describe the equipment and where/how it will be moved: _________
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Returned Space Checklist - continued
Environmental Health and Safety:
Is there anything in the space that needs EH&S review:
If Yes, has EH&S Lab Safety Status form been completed:
If Yes, please described the items needing EH&S review: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
For WUSM Facilities Use Only:
Entry/Exit doors re-keyed to WUSM Facilities Only: Date Changed: _____________ Master Key Type: ________________
Cleaning / Repairs:
Who will be cleaning the space:
Notes regarding cleaning or any needed repairs: _________________________
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