RIA 758 Facility Equipment Repair Request Form

							RIA-758 Appendix A
Seattle Children’s Hospital Research Institute, Building 1
Facility and Equipment Repair Request Form

Requestor Details
Requestor Badge:*
Requestor Name:*
Requestor's Phone #:*
Requestor Email:*

Work Request Location
Building Code:*
Floor Code:
Room Code:

Problem Category: *
[_] Facilities; [_] Lab


Equipment
Equipment Type:
RI Number:



                                                                   Reference the RI tag
Comments:                                                           affixed to the item.


Work Request Description
Urgency:*                  [_] Immediate; [_] 24 Hours; [_] 1 Week; [_] 1
                           Month; [_] Non-Urgent
Details [Describe Need]: *




Charge Direction
Accounting    Account Code   Activity                   Account             Est. Amount
Unit                                                    Category


Cost Approval Signature:

Vendor Performed Repair
Anticipated performance Date:
Submit Completed Form to Jeff Lonien, Director, B&E
* indicates a required field