Dept of Land, Air and Water Resources - Admin & Finance - Health & Safety

Skip directly to: Navigation for this section | Main page content

Admin & Finance » Health & Safety » Field Safety » Safety Form

Field Research Safety Training

INSTRUCTIONS: Complete all items below. If you are traveling to more than one location chose emergency information marked as #1 and #2. After you click on the "submit" button you will receive an email with this information. PRINT the email and TAKE it with you on your trip so you will have the emergency phone numbers if needed. This information will be kept on file with Dianne Louie (LAWR - Health & Safety Coordinator) in case of emergency. * = Required Field

Question	Response
* Name of travel leader:
* Travel leader email address (this address will receive form confirmation for printing):
PI of group (if different from travel leader):
* Group members traveling:
Home facility
* Date leaving home facility:
* Date returning to home facility:
* Trip itinerary: You may copy and paste to this section.
* Standard Operating Procedure: You may copy and paste to this section.
#1 Emergency information - Sheriff Station or Police phone number. Choose county of destination:
#1 - County health dept phone number. Choose county of destination:
#1 Nearest medical facility phone number:
#2 Emergency information - Sheriff Station or Police phone number. Choose county of destination:
#2 - County health dept phone number. Choose county of destination:
#2 Nearest medical facility phone number:
* I will have the following items with me:	Clean water First aid kit (check supplies) Group members have employee or student ID
Is personal safety protection equipment required? If yes, I will have it with me.	Yes No
Is a portable eye wash/shower for work involving corrosives required? If yes, I will have it with me.	Yes No
Will I be in an isolated location? If yes, I will have medical provisions needed.	Yes No
Is First Aid training required before taking this trip? If yes, employee must have a written record of first aid training with the American Red Cross on file with supervisor.	Yes No