Fieldwork Safety Planning Form
Instructions:
This form is not of fixed length. Please answer in red for each field.Use as much space as you need. Please write n/aif the field is not applicable.
Please submit completed form with signatures on the final 2 pages as a .pdf to Juana Pasco (Tel: 407 823 6525)
Section 1Updated Basic Safety information
Last name/s
First name/s:
Date of birth:
UCF PID:
month/year of entry to UCF
Faculty Advisor/Mentor:
UCF Email:
Other Emails:
Telephone numbers:
Cell:
Others:
Current Address:
Primary Emergency contact
Name and relationship:(e.g. parent, spouse, other family member, friend etc.)
Address:
Telephone number:
Email:
Secondary Emergency contact
Name and relationship:
Address:
Telephone number:
Email:
Medical: (optional but highly recommended):
Blood type:
Known allergies to medicine:
Known allergies to foods:
Other known allergies: (e.g. to bee stings)
Other relevant known medical conditions:
Prescription medicines:
Section 2 Summary description of Research and Field Sites
2.1. Thesis title (if defended) or Provisional thesis title if as yet undefended:
Describe briefly your intended field activities - including the kinds of habitats you will work in, what sort of methods you will use, and how you will access field sites.
2.2. EH&S First Aid course attended? Answer yes or no
2.3. List other first aid and safety related certifications relevant to your field work:
2.4.List nearest emergency health facilities to location/s of field work.
2.5. Other relevant emergency facilitiesin area e.g. nearest coastguard stations
Section 3 Descriptions of potential field risks
Do not enter standard life risks such as road traffic accidents on route to research unless the field research per se poses risks. For each of the categories and questions below describe and explain the activities, describe potential risks and how they can be mitigated by preparation, adequate equipment, training, and other precautions. List your experience and any relevant certification and licensing. List also anyplanned certification/licensing you are required to or wish to complete. Use as much space as you like. Enter “not applicable” (n/a) in a section that is not relevant, rather than leave it blank.
3.1. Off road vehicles.
Describe any use of off-road vehicles (e.g. all-terrain vehicles).
3.2. Water hazards:
3.2.1. Will your research be in, near or on water bodies, including in boats?
3.2.2. If yes, circle below:
i. I cannot swim. ii. I can only just swim. iii. I am a weak swimmer. iv. I am a moderate swimmer. v. I am a strong swimmer.
Do you have any swimming certifications or life-saving certifications?
3.2.3. Will your research be in or near swamps, tidal flats, or quicksand?
3.2.4. Will you operate any kind of boat or canoe (with or without engine)?
3.2.5. Will you operatepowered vessels (e.g. boat with inboard or outboard engine)?
3.2.6. Will the boat you operate or travel in be licensed and certified by the local authorities (e.g. US coastguard), along with its safety equipment specific to the type and size of the vessel (including life jackets)?
3.2.7. Will you wear a life jacket when working in boats or other vessels?
3.2.8. Are you prone to seasickness? If so what medicines/treatments will you seek?
3.2.9. Will you use SCUBA equipment?Provide a detailed description of activities (including times of dives, approximate depths, any special risks such as entering structures) in addition to the general responses required (see bold text under title for Section 3).
3.2.10. Where is the closest hyperbaric chamber?
3.2.11. Do you propose to dive alone?
3.3. Fall hazards:
Will you climb trees or cliffs etc.?
3.4. Underground hazards:
Will you enter subterranean caverns, potholes, mine shafts or other such systems?
3.5. Animal hazards:
Will you handledangerous animals as part of your research?
Is there a reasonable chance that a dangerous animal that is not the direct focus of your research could pose a danger?
3.6. Dangerous tools and equipment, weapons, reagents etc.
Will your research involve the use of potentially dangerous tools (e.g. chainsaws, machetes), dangerous chemical agents, or weapons such as firearms, air guns, other projectile devices?
3.7. Aircraft
Will you use aircraft other than scheduled or chartered passenger flights operated by registered and certified carriers in good standing with the US Federal Aviation Authority? (e.g. for aerial mapping, surveying, telemetry)?
Do you propose to pilot any kind of aircraft (including microlights, balloons etc.)?
Do you intend to use remotely operated aerial drones? If the answer is yes please focus on the safety issues, not on permitting (drone use is tightly regulated in most countries and typically require licensing).
3.8. Wilderness:
3.8.1. Will your work in remote areas (not within easy reach of major roads or settlements, or offshore). If so, describe activities, systems for provisioning food and water, navigation protocols, communication protocols.
3.8.2. Will you work alone? If so, please describe any potential special risks.
3.8.3. Will you work in areas with no cell phone contact? If so, will you require a satellite phone, radio, or distress beacon system such as EPIRB?
3.9. Parasites and disease:
Are there any potentially dangerous parasites or diseases in the area where you will research? If so, briefly describe, describe your efforts to consult with health care specialists about available protection, vaccines/medical procedures etc.
3.10. Other potential safety risks:
Describe any additional risks associated with field research not addressed above, including natural risks (e.g. earthquakes, wildfires) or human risks. Describe training and experience that may mitigate risk.
3.11. First Aid:
Will you carry a first aid kit? If so please summarize the contents.
3.12. Safety plan:
Describe a communication and evacuation plan in the case of a predicted accident or emergency during your normal current or predicted field activities.
Describe how you will inform people that you will enter the field (e.g. Float plan for boat use, informing authorities before entering wilderness etc.).
Section 4
I volunteer the following information about my health which could be useful in the case of an emergency, and procedures which others should follow: (e.g. a diabetic student might add an action plan here).
Section 5: Overseas Research.
Overseas researchers will need to regularize visas, export and import arrangements for goods and equipment, collection and scientific research permits, and arrange international travel with the appropriate UCF travel, finance and certification departments. This form is specifically and only concerned with safety aspects related to the field research you will undertake overseas. Please do not replicate information about these matters in these forms. If this country you propose to visit is in a US State Department list of restricted countries you will need to seek authorization via the relevant UCF department, but this does not need to be mentioned here.
5.1. Will your research be conducted overseas?
5.2. Where? List country or countries, regions, types of habitats etc.
5.3. List specific natural dangers not already listed in Section 3 that are specific and unique to the country and region you will visit, and discuss safety plans and other means of mitigating such risks.These include natural risks (e.g. earthquakes) or human risks.
5.4.Note any restrictions or special dangers, note if any region is listed on US State Department as hazardous/restricted.
5.5. Have you obtained an overseas travel insurance card from UCF Environmental Health and Safety? All UCF employees are eligible for this.
5.6. Will you be hosted by a foreign research organization or university? If so provide details of the arrangement.
5.7. What is your level of fluency in the local language/s? Will you be accompanied by coworkers who speak the local languages, or by interpreters?
5.8. Where do you anticipate staying (hotels, camps, boats etc.)?
5.9. How far will you be from hospitals?
5.10. Will there be cellphones or VHF radios to summon help in an emergency?
5.11. Will you need a satellite phone? (UCF Environmental Health and Safety can provide these)
5.12. Are there any special vaccination requirements for the region you will visit? If so, please indicate willingness to obtain all necessary immunizations from your doctor or from a clinic (the UCF Health Clinic has a full travel immunization service).
5.14. Please describe additional precautions you will take in the case of insect-transmitted diseases such as malaria (repellents, clothing, sleeping nets, consultation with locals about ‘hot spots’).
5.15. Please describe additional precautions you will take against known water borne diseases in the area (boiling, treating water etc.).
Note: For overseas field work, you are required to submit an emergency contact list for all expedition members prior to your departure. This must be copied to your main emergency contacts (with clear instructions that you may be out of contact for extended periods of time) and to Karen Reinemund.
Statements and Signatures
Student:
I have filled in this form to the best of my ability. I am willing and able to do the field work described here, and do so of my own volition. I am aware that all field work has risks and that some of these are unidentifiable.
Summary of training/certification yet to be completed:
Further, I pledge to complete the training listed below. I understand that it is my responsibility to remember to do so, and I will email the departmental Safety Contact on completion of these training activities so that the statement may be added as addenda to this document.
Comments
Signature ______
Name and date ______
List here certification and training that has yet to be undertaken:
Responsible faculty member:
Liability waiver:
I have discussed field safety provisions with the above-signed student and have read the above statement.
Comments:
Signature ______
Name and date ______
Chair Acknowledgement:
I am aware of this request to conduct field research.This form and any associated information will be held in digital and hard copy form at the Department of Biology.
Comments:
Signature ______
Name and date ______