Request for Research Space at InCHIP to Run Participants The information below is required to request InCHIP research space. Please fill out the following form (which will take approximately 10 minutes). Once your request is reviewed by one of the InCHIP Directors, you will be contacted by an InCHIP administrative staff member.InCHIP InformationName* First Last Phone*Email* Department/School at UConn*What is your position at UConn?*FacultyResearch ScientistResearch Associate/AssistantGraduate StudentUndergraduate StudentOtherPlease describe your position at UConn*Are you an InCHIP Affiliate?*YesNoIf you want to become an InCHIP Affiliate, you can find more information here.Who is the Principal Investigator (PI) or faculty member supervising this project?*If you are the supervising PI or faculty member, please list your own name here.Is the supervising PI or faculty member listed above an InCHIP affiliate?*YesNoResearch Space RequestProject Title*Is this project funded by an InCHIP internal or external grant?*YesNoWhat is the KFS number of the grant?*How is this research consistent with InCHIP's Mission Statement?*InCHIP Mission Statement: http://chip.uconn.edu/about/mission/Please check what room(s) you are requesting to use for your research* Interview Rooms (First Floor, Rooms 10-13), J. Ray Ryan Building Interview Rooms (Second Floor, Rooms 218-222), J. Ray Ryan Building Office/Interview Room, Rudd Center, Hartford A description of facilities available through InCHIP is available here.Please include all date(s), day(s) of the week, and times requested for this project. (e.g. "every Monday and Wednesday from 1-3pm between 6/20/16 and 7/6/16")*Please note that if the space is being requested for a time before 8am, after 5pm, or during the weekend, InCHIP building cards (UConn ID card or InCHIP-issued proximity card) will be required for entry. During non-business hours, for security reasons, the hallway doors leading from the first floor lobby area to the office space, as well as the door at the top of the stairs leading to the second floor interview rooms, are on the same schedule as the main entrance. These hallway doors should remain closed (not propped open) during non-business hours to ensure the safety and security of all individuals and equipment in the building. InCHIP’s main access doors should always remain closed and never be propped open.How many participants will be run in the requested space during any given session?*If you are a graduate student, will your Faculty Advisor or Faculty Supervisor be in the building during the times listed above?*YesNoI am not a graduate studentDo you have any IT support needs?*YesNoPlease specify your IT needs below.*NameThis field is for validation purposes and should be left unchanged.