Hazard
Suggested Precautions
Other Precautions
Communicable Disease
No
Review regional travel advisories
Ensure appropriate vaccinations
Ensure appropriate prophylactic medication
Insect controls (netting, repellent)
Health Conditions
E.g., Allergies, diabetes,
conditions requiring medication
No
Encourage participants bring adequate
supply of required medication
Predatory Animals
No
Research habitat/behavior
Pepper spray
Firearms
Firearms/Weapons
(type: _____ ____________)
No
Firearm license (PAL) issued to person
carrying firearm
Training on safe use
Venomous Animals/Plants
Research habitat/behavior
A
ntidotes (if available)
Department of Integrative Biology Field Course & Field Trip Safety Form
To be submitted to the IB Department Chair for approval prior to entering the field.
Office use only
Refer to University of Guelph Safety Policy 851.06.23 for additional details.
Field Research
Principal Investigator:
Contact #:
Time Period (annual renewal): __________________ to __________________
(dd/mm/yyyy) (dd/mm/yyyy)
Number of people in the working group: ______________
Is the number appropriate for this particular field situation? Y N
OR
Field Course/Trip Leader:
- For on-campus trips, names and contact information for participants are to be entered in Appendix A
- For off-campus trips, participants must submit Release and Indemnification Form in Appendix B
Location of Activity:
Brief Description of Activity:
Communication and Emergency Response
What communication equipment will the field course/trip participants have access to?
Cell phone
(#_________________)
Satellite phone
(#_________________)
Local hard line
(#_________________)
Radio
Locator beacon
What is the contact number for local emergency response/medical evacuation? (#_____________________________________)
First aid kit available? Yes No
Number of personnel trained in first aid ___
Possible Hazards - Indicate concerns relevant to your group:
1
Work at Height
Fall protection is required at
heights >3m
No
Training on ladder safety
Climbing equipment (& training)
Boating
Valid license
Required equipment (see below)
Electroshocking
Back-pack
Generator
No
Non-conducting boat hull (if applicable)
CPR trained personnel
Rubber boots & gloves
Marine/Aquatic
No
Research local current/surf
Chest waders
Safety/throw line
Life jacket/flotation device
Vehicles
Cars/Trucks
ATVs
Snowmobiles
Tractors
No
Valid license(s)
Driver Information Profile complete
Adequate insurance coverage
Training on safe operation of equipment
Car/truck checked for spare tire & jack
Hazardous Materials
Radioisotopes
Compressed Gas
Explosives
Biological
Chemical/other haz materials
No
WHMIS Training
TDG Certification
Personal Protective Equipment
Biosafety/Radiation permits issued (if
applicable)
r: ________________________________
Is a boat being used? Yes No
Name of operator card holde
Please check if boat is equipped with the following: Life jackets
Flashlight/flares
Air horn/whistle
Bailing bucket
Fire extinguisher
Oars
or Anchor/line
15m buoyant rope
First Aid Kit
Radio Drinking water Compass & charts Knife Spare gas tanks
Required equipment for powered pleasure craft refer to www.tc.gc.ca/marinesafety for more details
The above information is accurate and I understand the safety concerns involved in this project.
Signature of Professor/Instructor: ___________________________________________________________
This form must be sent to the Chair of the Department of Integrative Biology for approval.
Signature of Chair of IB: ___________________________________________________________
*Following approval, the department will submit a copy (minus Appendix A) to the Risk & Insurance Manager (5
th
Fl. UC) as per 851.06.04.
- Principal Investigator/Instructor keeps a copy
- Department keeps a copy
- Department sends completed form, minus Appendices, to Risk & Insurance Manager (5
th
Fl. UC) as per 851.06.04.
2
click to sign
signature
click to edit
click to sign
signature
click to edit
Appendix A On-Campus Field Course/Field Trip Participant Contact Information (e.g. Dairy bush, Arboretum ...)
Name
Contact Number (home/cell)
Contact number for next of kin
3
Appendix B - Page 1 (needed when trip is off-campus)
RELEASE and INDEMNIFICATION FORM
for FIELD TRIPS, EXCHANGES or EXCURSIONS
Name:
Student Number:
Course:
Field Trip, Exchange or Excursion:
Date of Field Trip, Exchange or Excursion:
I am aware that during this field trip, exchange or excursion (the” Excursion”) in which I am participating under the
arrangements of the University of Guelph, certain risks and dangers may exist, including but not limited to the hazards of
traveling, accidents or illness in remote places without medical facilities, the forces of nature and travel by air, train,
automobile or other means. More particular risks for this Excursion may include but are not limited to:
I accept and fully assume all risks, dangers and hazards and the possibility of personal injury, death,
property damage or loss, resulting from my participation in this Excursion.
In consideration of approval to participate in this Excursion, I, for myself, my heirs, next of kin, executors, administrators and
assigns agree to hereby release and forever discharge the University of Guelph, its officers, directors, servants, employees and
agents from any and all actions, claims and demands for damages, loss and injury, howsoever arising which now or may hereafter
be sustained by me in consequence of my participation in the above-noted Excursion.
I also acknowledge the University of Guelph does not carry accident or injury insurance for my benefit and also that there may be
certain matters for which I could be held at fault personally. In these cases, I agree to be accountable in all respects for my own
conduct and all actions, claims and demands for damages, loss and injury which may arise as a result of my own conduct. I
acknowledge and agree not to ask the University of Guelph, its officers, directors, servants, employees and agents to accept the
consequences thereof and agree to indemnify the University of Guelph, its officers, directors, servants, employees and agents from
any claims or demands which might be made against the University of Guelph, its officers, directors, servants, employees and
agents arising out of or as a result of my own conduct.
I declare that I have read and understood the above Release and Indemnification Form for Field Trips,
Exchanges or Excursions in its entirety and I hereby agree to be bound by the terms and conditions. I am
aware that by signing this agreement, I am waiving certain legal rights which I, my heirs, next of kin,
executors, administrators and assigns may have against the University of Guelph, its officers, directors,
servants, employees and agents.
Date: _____________________________
Signature __________________________________ _________________________________
Participant Witness
Note: If the Participant is not of legal age, this Release and Indemnification MUST be accompanied by the properly signed
Parental Release and Indemnification Form for Underage Participants.
click to sign
signature
click to edit
Appendix B - Page 2
Basic Safety Regulations
1 You should ordinarily travel and work in pairs or larger groups whenever the whole group splits up. There may be
occasions when you travel or work alone. In such cases, it is important to inform others of your destination, and
anticipated time of return. Please remain with the group at all times otherwise.
2 Persons with severe allergies are responsible for carrying the appropriate antidote kit.
3 Persons with particular medical or dietary needs must advise the course co-ordinator(s) and are responsible for carrying
the appropriate medicines or food.
4 It is critical to review all supporting course materials, especially those describing the specific risks associated with the
particular areas in which the excursion will be conducted.
EMERGENCY CONTACT INFORMATION
Nam
e: ____________________________________ Student Number: ______________________
Field Trip, Exchange or Excursion: ____________________________________
OHIP Number: ____________________________________________________
Health Information: Do you have any allergies, drug sensitivities or any other medical condition of which the course co-
ordinator(s) should be aware? If so, please specify:
Emergency Contact:
Name: ________________________________ Relationship: ___________________________
Address: _____________________________________________________
Phone Number: _______________________________ _________________________ __________________________
Daytime Evening Cell
I acknowledge that I have read the information contained on this Excursion Safety Sheet. I acknowledge that I am responsible for
my own safety and for advising the course co-ordinator(s) of any medical condition which may impact on my participation in the
Excursion. Since emergency medical treatment may not be available at all times during this Excursion, I also acknowledge my
responsibility to travel with whatever medications necessitated by the above-noted condition.
Date: _____________________________
Signature __________________________________ _________________________________
Participant Witness
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome