**SPACE SPECIFICATIONS**

**GENERAL SERVICES ADMINISTRATION**

**NOTE:** Many of the items described in this form are above standard
reimburs­able. Check with your GSA representative to determine which are
extra cost.

**[SECTION I. INTRODUCTION]{.underline}**

**A. Agency/Bureau:** **[AREA INDIAN HEALTH SERVICE]{.underline}**

**B. Location Requested:**

**C. Delineated Area:**

> In smaller towns this will normally be city wide. In larger cities it
> will be the Central Business Area (CBA) unless you have a requirement
> otherwise. If other than city wide or CBA, outline delineated area by
> streets and provide justification. If other than CBA or city wide,
> please include map.

**D. Is this request for space consistent with your agency\'s space
reduction plan?** If not, it must be certified by the head of your
agency in accordance with Section 101-17.101(c) of the Federal Property
Management Regulations.

**E. Name and Telephone Number of Agency Contact:**

**F. Will agency require the use of GSA Space Planners?** Yes
No[\_\_]{.underline}

**SECTION II. [SPACE REQUIREMENTS]{.underline}**

**A. Date Required:**

**B. Minimum firm term of lease:** ( )5 yrs. ( )10 yrs. ( )Other (This
is the noncancelable lease term based on the agency\'s best knowledge of
continuing needs. Normally, alterations for agency cannot be amortized
in less than three (3) years.)

**C.** **Number of occupants**: **Occupiable square feet**:

  --------- ------------ ----------- ------------ ------------ ------------
  \*Male    \*Female     Office      Storage      Special      Total

                                                               
  --------- ------------ ----------- ------------ ------------ ------------

\*(Needed to determine toilet facility requirements.)

**\"Storage\"** means non-airconditioned space with low lighting level
and no carpet. A room for office forms or related items that is finished
as office is classified as office.

**\"Special\"** means laboratories, computer rooms, large conference
rooms or other construction requiring special features.

D. **Is there a seasonal peak staffing level?** ( )Yes ( )No

**E. Is there a second or third shift?** ( )Yes ( )No

**F. Will multiple occupancy work stations be used?**( )Yes ( )No

**SECTION III. [LOCATION CONSIDERATION]{.underline}**

**A. Must your space be on contiguous floors?** ( )Yes ( )No

If yes, Explain:

**B. Must your space be located on one floor only?** ( )Yes ( ) No

If yes, Explain:

**C.** **Must you be located on a particular floor?** ( )Yes ( ) No

If yes, Explain:

**D. GSA cannot guarantee that all of your space will be contiguous,
therefore, on a functional basis, what is the minimum size requirement
for a single block of contiguous space?** **Please explain.**

**E. Identify any other agencies which you must be located near and
explain why:**

**F. Identify any agencies you should not be located near and explain
why**:

**SECTION IV. [STRUCTURAL REQUIREMENTS]{.underline}**

**A. Will you have a ceiling height requirement in excess of 8 feet?**

( )Yes ( )No If yes, Explain:

**B. Will you require any specially constructed areas such as a vault?**
( ) Yes ( ) No

If yes, Explain:

**C. Will you have an unusual floor load requirement?**

( )Yes ( )No (Such as power files, safe, central file room or
libraries?) If Yes, explain:

**SECTION V. [TRANSPORTA­TION]{.underline}**

**A. How many parking spaces will be required for official vehicles?**
(Parking for employees is not authorized except as required by

> local codes.)

**B. Will secured parking be required?** ( ) Yes ( ) No

**C. Is bus service required?** ( ) Yes ( ) No

If yes, how close to the nearest bus stop?

**D. Will a loading dock be required?** ( ) Yes ( ) No

1\. What size trucks will it have to accommodate?

2\. Will it have to be enclosed? ( ) Yes ( ) No

**E. Will a freight elevator be required?** ( ) Yes ( ) No

**SECTION VI. [ARCHITECTURAL]{.underline}**

**A. [Partitioning ]{.underline}**

> List the rooms you expect to need in the space below with remaining
> open area the last line item. **Be sure that the total square footage
> including the open area, matches the total square footage listed under
> the [SPACE REQUIREMENTS SECTION.]{.underline}** If additional space is
> required, please use this format on a separate sheet. Partition height
> will be slab to slab (s/s), ceiling (c/h), 6\' high or acoustical
> screens(A/S).

  ---------- ----------- ----------- ------------- ------------------ -----
  No. of     Area of     Total Sq.   Partition Ht. Intended Use       STC
  Rooms      Each        Ft.                                          

                                     C/H           Private Office     37

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

  Totals                                                              
  ---------- ----------- ----------- ------------- ------------------ -----

**B. [Partitions: Sound Conditioning:]{.underline}**

> This means walls constructed to reduce or prevent the transmission of
> sound. A normal office should have an STC(Sound Transmission
> Coefficient) of 37. A conference or hearing room will require an STC
> of 40. In rare instances where discussions occur which would have
> harmful effects on the Government if overheard, an STC of 50 may be
> required.
>
> Requirement for stick-on acoustical wall tiles, acoustical
>
> panels or other requirements to reduce noise level
> [within]{.underline} a room should be listed on a separate sheet.

**C. [Partitions: Folding ]{.underline}**

> If a folding wall will be required, please provide information on
> size, use, and STC on separate sheet. NOTE: GSA Fire safety
> regulations may preclude the use of folding partitions in certain
> situations.

**D. [Floor Covering: ]{.underline}**

> Standard floor covering for office space is carpet. If something else,
> such as vinyl tile is required for storage or file room, outline the
> requirements here:

**E. [Window Treatment: ]{.underline}**

> Standard window treatment is either lined drapes or unlined drapes
> with thin slat blinds. List your preference here.

SECTION VII. [MECHANICAL, ELECTRICAL, PLUMBING]{.underline}

**A. [Laboratory: ]{.underline}**

> If laboratory space is required, please list all requirements.

**B. [Plumbing: ]{.underline}**

> If sink, showers, exhaust fan or other special plumbing or mechanical
> system is required, please list here:

**C. [Chemicals: ]{.underline}**

> If chemicals are used, please list acids, corrosives, toxic or
> flammable chemicals by name, type, and quantity on hand at any one
> time.

**D. [Electrical: ]{.underline}**

> **1. Number of standard duplex electric outlets required:**
>
> **2. Special electrical requirements (other than computer):**
>
> **Include special requirements for photocopiers, remote computer
> terminals, etc.** Include information on voltage, amperage, cycle,
> phase, if separate or isolated circuit, type of ground (if special)
> special outlet requirements. Also include information on BTU\'s of
> heat generated by equipment:

**E. [Telecommunications: ]{.underline}**

> **1. Number of standard telephone outlets required:**
>
> **2. Number of special telephone outlets:** (Specify unique
>
> attributes)
>
> **3. Special telecommunications requirements such as leased equipment,
> lessor provided equipment, PBX, FTS, special switchgear, special
> environmental considerations, ADP links, wiring requirements.**

**SECTION VIII. [SERVICE AND UTILITIES]{.underline}**

**A. Do you have a requirement for a flag pole?** ( ) Yes ( ) No

> If yes, Explain:

**B. What are your normal hours of operation?**

**C. Is overtime access and utilities be required?** ( )Yes ( )No

> If yes, What frequency?

**D. Will daytime cleaning be required?** ( )Yes ( )No

> Justification:

**SECTION IX. [FIRESAFETY]{.underline}**

**Do you have any special fire safety requirements?** ( )Yes ( )No

If yes, Explain:

**SECTION X. [SECURITY]{.underline}**

List special requirements (if any) such as location within a building,
slab-to-slab walls, vaults, special guard requirements, special locks,
internal locks, alarm systems, etc.:

**SECTION XI. [COMPUTER ROOM]{.underline}**

**A. Will you require a computer room?** ( )Yes ( )No

> If no, proceed with SECTION XII. If yes, approximately what size
> (square feet)?

**B. Will the computer room require a raised floor?** ( ) Yes ( )No

> If yes, indicate height above existing floor:

**C. What live load should the floor support (psi)?**

**D. What are the maximum and minimum temperatures allowed in the
computer room?** Maximum Minimum

**E. Will these environmental conditions have to be maintained 24**

> **hours a day, 7 days a week?**

**F. Will any equipment be cooled from an underfloor system?** ( )Yes (
)No

**G. Please list each piece of equipment to be located in the**

> **computer room along with the operating BTU\'s of heat output and
> complete electrical requirements of each item. List in following table
> form on a [separate sheet.]{.underline}**

  ------------ --------------- ------------- ---------- ----------- ----------- -------------- ----------------------
  **Equip.**   **BTU\'s/Hr**   **Voltage**   **Amps**   **Phase**   Grounding   **Isolated**   **Hardwire/Plug-in**
                                                                    Req\'mts.                  

                                                                                               

                                                                                               
  ------------ --------------- ------------- ---------- ----------- ----------- -------------- ----------------------

**H. Where equipment will plug into a wall outlet (or floor outlet),
please tell us if the computer equipment vendor, your agency or GSA is
to furnish the outlets.**

**I. Where GSA will Furnish, please provide complete specifications of
electrical outlets, including catalog numbers:**

**J. Will you require a portable power center?** ( ) Yes ( )No

**K. Who will furnish signal cable to interconnect computer**

> **equipment?**
>
> If furnished by GSA, please provide complete specifications and
> quantities, and let us know if cable can be spliced?

**L. Who will hook up the computer cable?**

**M. Who will plug in or hard wire the computer equipment?**

**N. Will cable runs to remote terminals be required?** ( )Yes ( )No

**O. Will an emergency power supply be required?** ( )Yes ( )No

**P. Will an uninterrupted power supply be required?** ( )Yes ( )No

**Q. Will you require any convenience type electrical outlets in the**

> **computer room for test equipment?** ( )Yes ( )No

**R. Will this room require telephone outlet or special telephone**

> **line?** ( )Yes ( )No

S. How many people will normally be present in the computer room?

**SECTION XII. [SPECIAL REQUIREMENTS]{.underline}**

**A. Do you have requirements for interior view windows?** ( )Yes ( )No

> If yes, list number, size and distance from bottom edge to floor:

B. Do you have a requirement for a radio/TV antenna? ( )Yes ( )No

> If yes, list type of mount, roof or ground, entrance head, type and
> size conduit, termination mount required and location:

**C. Do you have a requirement for a Public Address System?**

> ( )Yes ( )No
>
> If yes, Describe:

**D. If you have a conference room, will you require any of the
following?**

> Exhaust fan ( )Yes ( )No Size CMF
>
> Chalkboards ( )Yes ( )No Size Liquid Chalkboards ( )Yes ( )No Size
>
> Built-in Screens ( )Yes ( )No Size

Projection booth ( )Yes ( )No Size

> Stage ( )Yes ( )No Size
>
> Blackout drapes ( )Yes ( )No Size
>
> Lectern ( )Yes ( )No Size

**E. What is the average number of people expected to attend**

> **meetings?**

**F. Will there be an executive area with higher standards of finish**

> **than the remainder of the space?** ( )Yes ( )No
>
> If yes, Explain:

**G. List any other special requirements not already covered:**

**SECTION XIII. [WAREHOUSE]{.underline}**

**A. If you need a warehouse, provide the following information:**

> 1\. Warehouse size: Square Feet:
>
> 2\. Hoist: ( )Yes ( )No
>
> If yes, Explain:
>
> 3\. Overhead door type**:** 4. Hose bib: ( )Yes ( )No Frost free (
> )Yes ( )No
>
> 5\. Floor drain:( ) Yes ( )No
>
> 6\. Floor type Floor load: 7. Loading dock(s): ( )Yes ( )No Height:
> Location: N/A 8. Concrete apron: ( )Yes (X) No
>
> 9\. Ceiling height:
>
> 10\. Number of Employees:
>
> 11\. Restroom ( ) Yes ( ) No
>
> 12\. Wareyard area necessary for maneuverability of vehicles?
>
> ( )Yes ( )No If yes, size in sq.ft.
>
> 13\. foot candles of lighting.
>
> 14\. Special HVAC ( ) Yes ( ) No
>
> If yes, Explain:

15\. Electrical requirements:

**SECTION XIV. [WAREYARD]{.underline}**

**Will you need a wareyard?** ( ) Yes (X ) No

If yes, provide the following information:

> A. Location: sq.ft.:

B. Surface type:

> C. Lighting ( ) Yes ( ) No
>
> If yes, Foot candles at ground level:

D. Fencing ( ) Yes ( ) No

> If yes, Explain:

E. Gates required ( ) Yes ( ) No

> If yes, Explain:
>
> F. Adjacency to other buildings:

**SECTION XV. [CERTIFICATION]{.underline}**

**The impact of the Balance Budget and Emergency Deficit Control Act of
1985 has been considered and funds are available to pay for the
requested space.**

BY:

(SIGNATURE) (DATE)

(AUTHORIZING OFFICIAL) (DATE)

**IF ADDITIONAL PAGES ARE NEEDED, USE PLAIN BOND, AND INDICATE WHAT
SECTION AND SUBSECTION IS BEING EXPLAINED.**