work request form facilities management division - NASA

WORK REQUEST FORM
FACILITIES MANAGEMENT DIVISION
GODDARD SPACE FLIGHT CENTER
CUSTOMER’S INTERNAL TRACKING #
FMD WORK REQUEST 3
INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE SECOND PAGE
1a. CUSTOMER NAME: 1b. CODE 2. TO:
4.
LOCATION
OF WORK:
CODE 222.1/WORK RECEPTION
3. TODAY’S DATE:
BUILDINGS(S) ROOM(S)/OTHER: EQUIPMENT ID # (IF KNOWN) 5. NEED DATE
6. DESCRIPTION OF WORK:
ATTACHMENT? YES
NO
7. JUSTIFICATION:
FOM REVIEW (INITIALS/DATE):
BLDG MGR REVIEW (INITIALS/DATE):
8. FOR INFORMATION, CONTACT: CODE: EXT.: BLDG.: ROOM:
9.
FUNDING DATA
(SEE INSTRUCTIONS)
APPROPRIATION: JOB ORDER NUMBER: BUDGET LINE ITEM: FISCAL YEAR:
APPROPRIATION: JOB ORDER NUMBER: BUDGET LINE ITEM: FISCAL YEAR:
10.
AUTHORIZING
SIGNATURE: DATE: PRINTED/TYPED NAME/TITLE/CODE:
OFFICIAL
(SEE INSTRUCTIONS)
11.
DIRECTORATE
SIGNATURE (FCC MEMBER/AUTHORIZED REP): DATE: NO. & TITLE FROM FCC LIST (IF APPLICABLE):
FCC REVIEW
(SEE INSTRUCTIONS)
FOR FMD USE ONLY BELOW THIS LINE
12. APPROVAL: 13. CONCURRENCE: 14. PRIORITY: 15. WORK TYPE: 16. CATEGORY: 17. CM/CC/TAM: 18. SECTION:
19. SHOP/SPEC.CASE CODE: SHOP/SPEC CASE CODE: SHOP/SPEC CASE CODE: SHOP/SPEC CASE CODE: SHOP/SPEC CASE CODE:
GSFC 16-48 (11/96) All previous versions of GSFC forms 16-35 and 16-47 are obsolete.

FMD SERVICES REQUIRING A WORK REQUEST FORM
At Goddard Space Flight Center-Greenbelt, the following services require a Work Request form: planning, design, and
direction for the construction of all new facilities and modification of existing facilities; and non-repair maintenance
services such as painting, special custodial services, and fabrication, etc. ALL ROUTINE REPAIRS, TROUBLE CALLS,
AND PEST CONTROL SERVICES SHOULD BE OBTAINED BY CALLING THE WORK CONTROL CENTER AT
x6-5555.
Note: At WFF, all services must be obtained by submitting an FMD Work Request form to the Facilities Management
Branch, Code 228.
INSTRUCTIONS FOR COMPLETING THE WORK REQUEST FORM
Be sure to fill in all blocks pertaining to your work request. If the block does not apply to you, write in “N/A” so that FMD is
assured that it was not overlooked. Thank you.
BLOCK 1:
BLOCK 2:
BLOCK 3:
BLOCK 4:
BLOCK 5:
BLOCK 6:
BLOCK 7:
BLOCK 8:
BLOCK 9:
BLOCK 10:
BLOCK 11:
BLOCK 12
THRU 19:
Enter the name and code of the original requester (the individual benefiting from the work).
Address where completed Work Request form should be forwarded.
Today’s date.
Address where work/service is to be delivered.
Enter the date by which you need work/service completed. Justify this date in Block 7, below. DO NOT
enter vague timeframes such as “ASAP.” Your work request will be scheduled in turn if a date is not
provided. Need dates for projects may be negotiated between FMD and the requester.
Describe the specific work you want done. Use an additional sheet if more space is needed.
Explain why you need the work done and why you need it done by the date indicated in Block 5. If the
proposed work is directly related to a flight, engineering or scientific project, identify the project. Have
your Facility Operations Manager (FOM) and Building Manager review the Work Request and initial in the
spaces provided. (FOM’s and Building Managers are listed in the GSFC Telephone Directory.)
Identify your point of contact that can provide additional details regarding the scope of work. This should
be the person that is most knowledgeable about the project, which will be the point of contact for the life
of the project, and the person to whom FMD will send project status reports/letters.
If your organization is paying for the proposed work, enter your funding data; otherwise, simply insert
“NA.” FMD Resources Office will confirm funds availability. Be certain that your job order number is
appropriate for the type of work being performed.
Authorizing official must be at the Branch Head level or higher.
Work Requests which are expected to exceed $2.5K should be authorized by your Directorate Facilities
Coordinating Committee (FCC) member. Customer-funded projects do not require FCC approval.
DO NOT write in these blocks—for FMD use only.
A confirmation of your work request will be forwarded to you. Please be sure to retain it for reference.