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University of Hawaii Application for Visiting Scientific Diver Authorization for visitors

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University of Hawaii Diving Safety Program
Appendix 1
Application for Visiting Scientific Diver Authorization
For all visitors except government employees
Section 1. Applicant Information Date:
Applicant Name:
Date of Birth: Sex:
Position: Faculty / Staff / Post-Doc / Student Employee / Student / Volunteer / Other:
Work Address:
Home Phone:
Daytime Phone:
Email: Cell Phone:
Are you a currently active scientific diver in a scientific diving pro
gram with which UH holds reciprocal
agreements? Yes / No
(circle one)
If YES, complete Application pages 1-4, and include a letter of
reciprocity from your home institution’s Diving Officer.
Name of Institution:
AAUS Member? Yes / No
Diving Safety Officer Name:
Phone:
DSO Address:
Email:
If NO, please complete all pages, including Application Section 2. Diving History, and return with (1) copies of all
referenced
certifications, (2) a copy of a diving medical clearance based on an AAUS-level diving medical exam, done
within the last year, and (3) evidence of personal scuba equipment service done within the last year.
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):
Sponsor Information:
Sponsoring UH Dept./Program: Phone:
Dept. Address:
Dept. Sponsor Name:
Position:
UH Sponsor Certification: I certif
y that this 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 Sponsor Signature: X
Rev 08/24/05
University of Hawaii Diving Safety Program
VISITING SCIENTIFIC DIVER ASSUMPTION OF RISK, WAIVER AND RELEASE
For all except government employees
(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,
including potential permanent disability and/or death
, and also such injury
may occur 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
activities undertaken as an adjunct thereto;
♦ I understand that diving operations may be conducted at remote locations at which a
recompression chamber is not available, and from which evacuation to such a chamber may be delayed
by many hours.
♦ I
r
ty. I understand I will not be penalized in my employment or academic record for any
♦
r
e to strictly
observe these rules. I understand that failure to comply may result in review, restriction, or revocation
My participation in diving is voluntary; that
I have the right and responsibility to refrain from diving if
feel the activity or conditions are not safe, that my fitness is not adequate for the dive, or for any othe
reason of safe
such refusal.
My authorization to dive is a privilege granted upon compliance with UH requirements. I will
follow the rules and precautions for conducting diving operations that are part of the requirements fo
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 agents, and I agre
of my authorization to dive
under University auspices by the UH Diving Control Board.
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
♦ nts,
rty damage or personal injury or death which may result from my participation and
which result from causes beyond the control of, and with or without the fault or negligence of the
iod
lly understand that by signing this form I am giving up legal
ghts an /or rem ing any losses I may sustain. I agree that if any portion is held invalid, the
mainder will continue in full force and effect. I agree that I have freely and voluntarily caused this release to be
er ag 18)
___________________________________ _____________________________________
(Print Diver Name) (Print Name, Parent or Guardian) Rev 8/24/05
negligence of the University, its regents, officers, employees, agents, volunteers, and assigns during
the period of my participation as aforesaid;
I also ag
ree to INDEMNIFY, DEFEND AND HOLD HARMLESS the University of Hawaii, its rege
officers, employees, agents, volunteers, and assigns from and against any and all claims, demands,
and actions for prope
University of Hawaii, its regents, officers, employees, agents, volunteers, or assigns, during the per
of my participation.
affirm tha
t I hav his form and fu
I e rea
d t
ri d edies regard
re
executed this date
, _____________,
(Date)
______________________ _____
_____________________________ _____________ ___
(Diver) (Parent or Guardian, if Diver is und e
2
University of Hawaii Diving Safety Program
VISITING DIVER MEDICAL CONSENT AND INSURABILITY
For all visitors except government employees
I, _______________________________________, consent to and authorize any
first aid provider, medical professional and others working under their supervision to
treat me for any injury or illness occurring during my University of Hawai'i (UH) -
affiliated diving activities.
(You must CHECK one of the following):
_____ EMPLOYEE: I am an employee or other compensated affiliate of my home institution and I am authorized
to conduct scientific diving as part of my employment. Through my employment, I have worker's
compensation coverage for job-related injury or illness incurred during authorized my diving activities
under UH auspices. As evidence of this, I attach the Employe
r's Indemnification and Responsibility
Statement for Visiting Scientific Divers.
_____ NON EMPLOYEE: I am a student, or other adjunct/affiliate of my home institution, who is not eligible for
worker's compensation coverage. I agree to pay any and all such medical expenses, costs and other
charges not covered by Workers Compensation or other insurance 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 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 follow
ing Divers' Alert Network (DAN)
Diving Accident Insurance, which covers the cost of emergency transport and medical care for diving
related injuries or illness:
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:
____________________________ _______________________________________________
____________________________ _______________________________________________
I affirm that I have read this form and fully understand that by signing this form I am 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
xecuted his date ________,
e t , _____
(Date)
___________________________________ _____________________________________
(Diver) (Parent or Guardian, if Diver is under age 18)
___________________________________ _____________________________________
(Print Diver Name) (Print Name, Parent or Guardian)
3
Rev 8/24/05
University of Hawaii Diving Safety Program
Employer's Indemnification Agreement and Statement of Responsibility
for Visiting Scientific Divers
For all visitors except government employees
In consideration of the University of Hawai'i (UH) providing the scientific diver named below with the opportunity
to engage in scientific diving activities under UH auspices, in conjunction with UH Scientific divers, at UH-
controlled diving sites, or using UH facilities, vessels and/or equipment in support of their diving,
the _________________________________________________________________________,
(parent organization)
Department of _______________________________________
__________________________, ("The
Organization") agrees to INDEMNIFY, DEFEND AND HOLD HARMLESS the University of Hawaii, its regents,
officers, employees, agents, volunteers and assigns from all claims, demands and actions, for property damage,
personal injury or death arising by reason of the acts or omissions of the Organization or the Organization's
scientific diver and which result from causes beyond the control of, and with or without the fault or negligence of
the University, its regents, officers, employees, agents, volunteers, or assigns during the participation of the
Organization’s scientific diver.
The Organization warrants and represents that it maintains workers’ compensation insurance on behalf of the
named diver, to the ex
tent required by applicable state law and/or statutory limits.
The Organization assures the University of Hawai'i that
_____________________________________________, _______________________________
(Scientific Diver's Name) (Position Title)
is a currently authorized scientific diver of the Organization
, as evidenced by the accompanying Visiting
Diver Application and AAUS Letter of Reciprocity or itemized documentation of diver training and qualification
and is employed by the Organization in a manner by which he/she 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, including emergency transportation costs if required for proper medical care of an injury or illness.
I certify that I am authorized to execute this Indemnification Agreement an
d Responsibility Statement on behalf of
the Organization.
___________________________/___________________________, ______________________
Department Chairperson or Personnel Officer Signature/Print Name (Date)
Department Address: ____________________________________________
____________________________________________
(____)_____________________ (_____)__________________ ___________________
_______
Dept. Phone Dept. Fax Dept. e-mail
INSTRUCTIONS: This completed form must be submitted with other pertinent ap
plications, waivers, letter of
reciprocity and/or other required documentation of the divers training and authorization, and dive plans at least 4
weeks prior to arrival at the University of Hawai'i to:
David F. Pence, Diving Safety Officer, University of Hawaii, EHSO, 2040 East-West Rd. Honolulu, HI 96822
Tel: (808) 956-9643 Fax (808) 956-6952 E-mail: dpence@hawaii.edu
Rev 08/24/05
4
PP. 5-7 TO BE COMPLETED BY VISITING DIVERS FROM AGENCIES WITH WHICH UH DOES NOT HOLD RECIPROCITY AGREEMENTS,
OR BY DIVERS APPLYNG FOR TEMPORARY DIVER AUTHORIZATION
Section 2: Diving History Name:
Part 1: Diving Training History
(Provide photocopies of all certificates and c-card
s
to document claimed training)
Date of First Certification:
Agency: Location:
Certification Type
Agency
Date
Cert.
Number
Course
Duration
Location
Openwater Scuba
Diver
Advanced Diver
Master Diver
Scuba Rescue
Leadership
(AI, Dive Master)
Instructor
Military Diver
Commercial Diver
Other Applicable Dive or Water Safety Training (List B
elow):
Type of Training Agency or School Date(s) Location
Part 2. Emergency Training History
Date of CPR Training:
Agency:
Name of Course:
Date of First Aid Training:
Agency:
Name of Course:
Date of Oxygen Training:
Agency:
Name of Course:
(Provide photocopies of all certificates and c-card
s
to document claimed training)
5
(Provide photocopies of all certificates and c-cards to document claimed training)
Part 3. Diving Experience
A. General
Years Diving
Age 1st Skin Dive: Age first Compressed Air Dive
Military Diving Experience
Type of Diving
Total
Years
Maximum
Dept
h
Total #
Dives
# Dives
Last Year
Cumulative
Bottom Time
Compressed Air SCUBA
Compressed Air Surface-supplied
Nitrox, Open-circuit SCUBA
Stage Decompression, O/C Scuba
Trimix/Heliox, O/C Scuba
Oxygen Rebreather
Semi-closed Circuit Rebreather
Closed-circuit Rebreather
One-Atm. Diving Suit
B. Activity Profile
v.
currentall pre
Dive Log Totals.
years
year
Life
Year………………………………………..
Total
Number of Dives.....................................
Deepest Dive ..........................................
# Dives with Nitrox 22-40% ....................
# Dives with Staged Decompression......
# Dives with Mixed Gas ..........................
# Dives/hrs. with SCR.............................
# Dives/hrs. with CCR ............................
Number of Dives per day: Maximum:
Average:
List approximate number of dives (Past Year)
in the following categories (enter 0 where appropriate)
Depth: < 30 ft:
30-60 ft: 60-100 ft: 100-130 ft: >130 ft:
Conditions:
Night: _ Low Visibility: _ Physical Overhead: Bluewater (No Bottom):___
Platform: Shore Small Boat Dives:______ Shipboard Diving:_______ Saturation:
Other (Describe):
C. Past experience with (indicate all that
apply with estimated numb
er of dives):
Sport Diving Research Education Marine Life Collecting
Net Tending Aquaculture Saturation Shipboard Diving
Rebreathers Mixed Gas/Stage Deco _____Hookah Commercial Diving
Other:
(Provide photocopies of all certificates and c-card
s
to document claimed training)
6
Part 4. Diving Injury History
A. Oronasal
Do you have difficulty clearing your ears on descent, or in aircraft? Yes / No
Does ear difficulty limit your diving? Yes / No
If yes, how often?
Have you ever experienced “ear squeeze” to the point of having temporar
y hearing loss? Yes / No
If yes, how often
Have you ever aborted a dive because of ear problems? Yes / No
If yes, how often?
Have you ever had difficulty with your sinuses during a dive? Yes / No
If yes, how often?
Have you ever had a sinus squeeze? Yes / No
If yes, how often?
Have you ever aborted a dive because of sinus problems? Yes / No
If yes, how often?
B. DCI
Have you ever had any form of decompression illness or other diving
related injury? Yes/ / No
(If Yes, attach separate statement, describing time, circumstances, nature of the injury, treatment that
you received, the ultimate outcome and any lasting effects.)
________________________________________________________________________________
APPLICANT’S AFFIDAVIT
: I certify that the above information is true to the best of my knowledge
and ability. I understand that misstatements on this report can result in loss of my diving privileges
under University of Hawaii Diving Safety Program auspices.
Signature of Applicant: X
Date:
(Provide photocopies of all certificates and c-card
s
to document claimed training)
7
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