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 RequestedSubject 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 ActivityBU IACUC Protocol Title* BU IACUC Protocol Number* Species*ChinchillaFerretGerbilGuinea PigHamsterMonkeyMouse–StandardMouse–IsolationMouse–ImmunodeficientPigRabbitRat–ImmunodeficientRatZebrafishOther Chinchilla Research EquipmentEquipmentDimensions 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.*