UTHSC-H
UTILITY SHUTDOWN REQUEST FORM



Project Name: Current Date:4/19/2014 Current Time:14:33
Project Number: *Start Date:   
*Start Time(military):
*End Date:  
*Building:
 

 
*Floor Affected:
Hold down CTRL button for multiple floors.
Room Locations:
*UT Representative : Company:
Email Address: Position:
*What system(s) are to be shut down?
This shutdown is required in order to:
GC Rep: Position:
*Company Doing Work: *Phone:
*Person Doing Work: Pager:
Number of hours needed to do work: Requested Shutdown Date:  

Do you agree to the following? (I agree box)
This request must be submitted by UTHSC-H Project Manager (in order to allow Facilities Operations' personnel to investigate and coordinate this request) a minimum of five (5) days prior to the requested shutdown date. Facilities Operations' shutdown coordinator will return to the UTHSC-H Project Manager a written copy of the scheduled time and day for the shutdown a minimum of two (2) days prior to the shutdown.

I agree to the above terms