Fillable University of Hawaii Application for Visiting Scientific Diver Authorization faculty and staff

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University of Hawaii Application for Visiting Scientific Diver Authorization faculty and staff

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University of Hawaii Diving Safety Program
Appendix 1
Application for University of Hawaii Scientific Diver Authorization
For University of Hawaii and RCUH Faculty, Staff and Students
Section 1. Applicant Information Date:
Applicant Name:
Date of Birth: Sex:
Position Title:
BOR Employee:
Faculty APT Staff Other
Non-BOR Employee:
RCUH Temporary Student Volunteer
UH Non-Employee:
Grad.Student Undergrad Other (Specify):
Address:
Home Phone:
Primary Phone:
Email: 2nd Phone:
Have you previously been as qualified scientific diver under a standard which UH recogni
zes as
equivalent to those specified in the UH Diving Safety Manual (AAUS, AS/NZ2299, etc…)?
Yes / No
(circle one)
If YES:
Name of Institution: AAUS Member? Yes / No
Diving Safety Officer Name:
Phone:
DSO Address:
Email:
Include an official letter from that institution’s Diving Officer verifying scientific diver training and qualification, with
copies of supporting documentation.
Planned Activity Information:
Describe Proposed Diving under UH auspices:
Initial depth range:
Expected activities (check all that apply):
biology/ecology collecting engineering geology oceanography
aquaculture archaeology science edu. Equip. placement/monitoring
field school attendee (identify course, dates):
UH Supervisor Information:
Sponsoring UH Dept./Program: Phone:
Dept. Address:
Dept. Sponsor Name:
Position:
UH Supervisor Certification: I certify that th
is individual has a need to participate in scientific diving activity under University
auspices for research or educational purposes, and agree to serve as a contact person and/or coordinator between him/her
and the Diving Safety Program, should the need arise.
UH Supervisor Signature: X
Receipt Date______
App. Complete____
Certificates ____
DAN Ins. ____
UDC Review ___
DSO Review ___
Data Entry ___
Rev 10/10/05
University of Hawaii Diving Safety Program
UH SCIENTIFIC DIVER ASSUMPTION OF RISK, WAIVER AND RELEASE
For University of Hawaii and RCUH Faculty, Staff and Students
(Read each paragraph, and sign below)
I, ______________________________________, the undersigned, in consideration of the University
of Hawai'i (UH) providing me with the opportunity to engage in scientific diving activities under UH
auspices, I agree that:
♦ I fully recognize and appreciate the dangers and hazards inherent in diving to which I may be
exposed during diving, including but not limited to arterial gas embolism, ear and/or sinus barotrauma,
decompression sickness, drowning, near-drowning, and/or dysbaric osteonecrosis and other long-term
effects, as yet poorly defined, and also during transportation to and from dive locations. I do hereby agree to
assume all the risks and responsibilities surrounding my participation in diving or any independent research
or educational activities undertaken as an adjunct thereto;
♦
chamber is not available, and from which evacuation to such a chamber may be delayed by many hours.
♦
of
♦ w
nts, and I agree to strictly observe these
rules. I understand that failure to comply may result in review, restriction, or revocation of my authorization
♦
o
I understand that diving operations may be conducted at remote locations at which a
recompression
My participation in diving is voluntary; that I have the right and responsibility to refrain from diving if I feel
the activity or conditions are not safe, that my fitness is not adequate for the dive, or for any other reason
safety. I understand I will not be penalized in my employment or academic record for any such refusal.
My authoriza
tion to dive is a privilege granted upon compliance with UH requirements. I will follo
the rules and precautions for conducting diving operations that are part of the requirements for my
authorization to dive under UH auspices, as set forth in the UH Diving Safety Manual, as well as those
procedures explained to me by the UH Diving Officer or his/her age
to dive under University auspices by the UH Diving Control Board.
FURTHER, IF I AM PARTICIPATING IN DIVING ACTIVITIES THAT
ARE NOT AN OFFICIAL ACT OF MY
UH/RCUH EMPLOYMENT:
I do for myself, my heirs, executors, and administrators hereby RELEASE, WAIVE, DISCHARGE
AND COVENANT NOT TO SUE the University of Hawaii, its regents, officers, employees, agents,
volunteers, and assigns from and against any and all claims, demands, and actions, or cause of action
on account of damage to personal property, or personal injury or death, which may result from my
participation, and which result from causes b
,
eyond the control of, and with or without the fault or
ing
o
ses beyond the control of, and with or without the fault or negligence of the
losses I may sustain. I agree that if any portion is held invalid, the
mainder will con t. I agree that I have freely and voluntarily caused this release to be
___________________________________ _____________________________________
(Print Diver Name) (Print Name, Parent or Guardian)
negligence of the University, its regents, officers, employees, agents, volunteers, and assigns dur
the period of my participation as aforesaid;
I agree to INDEMNIFY, DEFEND AND HOLD HARMLESS the University of Hawaii, its regents,
officers, employees, agents, volunteers, and assigns from and against any and all claims, demands,
and actions for property damage or personal injury or death which may result from my participation and
which result from cau
University of Hawaii, its regents, officers, employees, agents, volunteers, or assigns, during the period
of m
y participation.
I affirm that I
have read this form and fully understand that by signing this form I may be giving up legal
ights an /or rem ing any
r d edies regard
e tinue in full
force and effecr
executed this date, _____________,
(D ate)
___________________________________ _____________________________________
f Diver is under age 18) (Diver Signature) (Parent or Guardian, i
2
Rev 10/10/05
University of Hawaii Diving Safety Program
UH SCIENTIFIC DIVER MEDICAL CONSENT AND INSURABILITY
For University of Hawaii and RCUH Faculty, Staff and Students
I, _______________________________________, consent to and authorize any first aid provider,
medical professional and o
thers working under their supervision to treat me for any injury or illness
occurring during my University of Hawai'i (UH) -affiliated diving activities.
(Initial one of the following):
_____ EMPLOYEE: I am an employee of the University of Hawaii or other compensated affiliate or volunteer and
I am authorized to conduct scientific diving as part of my official duties. Through my employment, I am
eligible for worker's compensation coverage for job-related injury or illness incurred during my
authorized diving activities under UH auspices. As evidence of this, I attach the UH Verification of
Employment for Scientific Divers.
_____ NON-EMPLOYEE: I am a student, or other uncompensated adjunct/affiliate of the University of Hawaii,
who is not eligible for worker's compensation coverage
. In consideration of being allowed to engage
in scientific diving under University auspices, I agree to RELEASE, DISCHARGE AND HOLD HARMLESS
the University of Hawaii, its officers, agents, assigns, and employees from and against any liability arising
from my participation or any claims or demands arising from or connected with such medical treatment or
care. As evidence of insurability, I attach a copy of my card for the following Divers' Alert Network
(DAN) Diving Accident Insurance, which covers the cost of emergency transport and medical care for
diving related injuries or illness. I agree to be responsible for payment of any and all medical expenses,
costs and other charges not covered.
DAN Member Number:___________ Coverage Level: ___________________ Expires: __________
(Minimum: DAN Standard Plan)
EMERGENCY CONTACTS:
1st Emergency Contact:_________________________
Relation: ___________________ ___
Home Phone: _____________________________ Work Phone:_____________________
Mailing Address: ___________________________________________________________________________
2nd Emergency Contact:_________________________ Relation: ___________________ ___
Home Phone: _____________________________ Work Phone:_____________________
Mailing Address: ___________________________________________________________________________
Please list any Allergies or Sensitivities that may affect you in the field, or during emergency treatment
(antibiotics, bee stings, etc...), of which the Diving Supervisor should be aware:
____________________________
_______________________________________________
____________________________
_______________________________________________
With reference to any activities that are not a part of any official duties as a UH employee, I affirm that I have
read this form and fully understand that by signing this form I may be giving up legal rights and/or
remedies regarding any losses I may sustain. I agree that if any portion is held invalid, the remainder will
continue in full force and effect. I agree that I have freely and voluntarily caused this release to be executed this
___________,
date, __
(Date)
___________________________________ _____________________________________
(Diver) (Parent or Guardian, if Diver is under age 18)
___________________________________ _____________________________________
(Print Diver Name) (Print Name, Parent or Guardian)
3
Rev 10/10/05
University of Hawaii Diving Safety Program
UH VERIFICATION OF EMPLOYMENT FOR UH SCIENTIFIC DIVERS
For University of Hawaii and RCUH Faculty, Staff and Students
The _______________________________________ ___________________________________ verifies that
(UH Campus) (Department)
_______________________________________, ________________________________________
Employee's Name Position Title
is employed in a manner by which he/she is authorized to participate in diving as part of his/her employment and
is eligible under state law or other statutory authority for worker's compensation benefits in the event of accident
or injury during the conduct of scientific diving activity.
The Employee is hired as a:
___ BOR Faculty ___ BOR Staff ___ RCUH Faculty ___ RCUH Staff ___Temporary/Casual Hire
___ Student Employee ___ Official UH Volunteer
___ Other: _____________________________
I certify that I am authorized to execute this verification.
_____________________________/____________________________ ______________________
Department Chairperson or Personnel Officer Signature/Print Name (Date)
Depa
rtment Address: ____________________________________________
____________________________________________
(____)_____________________ (_____)__________________ __________________________
Dept. Phone Dept. Fax Dept. email
INSTRUCT
IONS: This completed form must be submitted with other pertinent applications, waivers and
documentation of the divers training and authorization to:
David F. Pence, Diving Safety Officer, University of Hawaii, EHSO, 2040 East-West Rd. Honolulu, HI 97822
T
el: (808) 956-9643 Fax (808) 956-6952 E-mail: dpence@hawaii.edu
4
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Completed 8 December 2019

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