Risk Management Form for Coordinators of International Activities and Safety
For a printable version of this form see under "forms" on the Laurier International website
Risk Management Form for Coordinators of International Activities and Safety
This form is to be completed (by the Activity Coordinator) and approved by the Department Director/ Chair prior to any activity in international locations including the United States. For Research Activities, please complete the Field Research Safety Planning Record instead. Additional sheets should be appended as necessary to capture the features of individual activities and any special safety provisions, as trips may be impacted by changes in season, political landscape, health and safety of the region. A detailed travel itinerary must also be attached.
- Submit completed form to the Department Director/ Chair.
- Any student or staff member organizing an individual trip must complete the form as “Activity Coordinator”.
- Department Director/ Chair must submit approved form to the appropriate Dean or VP for final approval.
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Department □ ____________________________
Student Group □ __________________________
Individual: □ _____________________________ |
Activity Coordinator (Applicant and overseer of Activity. May or may not lead the Activity): Name: __________________________________
Email:___________________________________
Phone:___________________________________ |
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Purpose of International Activity: □ Academic: Undergraduate ____ Graduate ______
□ Research □ Other extracurricular |
International Activity Leader (if different fromC oordinator ): Name: ___________________________________
Email: ___________________________________
Phone: ___________________________________ |
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Nature of International Activity (include team name, course, etc. if :
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Location of International Activity: Country: Geographical Site: Nearest City (name, distance to): Please attach a complete travel itinerary (location, dates, map if applicable) |
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Mode(s) of Transportation (check all that apply, and provide information) University Vehicle _______________ Private Vehicle* _________________ Rented Vehicle* _________________ Commercial Carrier ___________________ Other (please specify) _____________________________________________ * Indicate the name of the driver. NOTE: University insurance does not provide coverage for private vehicles. Collision coverage and $2,000,000 personal liability coverage recommended, minimum of $1,000,000. |
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Date of Departure:
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Date of Return:
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Chain of Responsible Leadership: List all those who have a leadership role |
CATEGORY (Check all that apply) |
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Team Leader |
Other (specify) |
Trained First Aider |
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NUMBER OF Participants (other than the leadership team listed above): ________ |
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Risk Assessment Form for International Activity
List identified hazards associated with activities or environment (e.g., extreme heat or cold, wild animals, transportation, crime, violence, disease, political instability), and risk-management measures planned or taken for eliminating or reducing risks to acceptable levels. Please see the attached examples. Append additional pages as required.
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Hazard Identification |
Risk Analysis |
Risk-Management Plan |
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I certify that in my capacity as Activity Leader I will ensure that the Activity described above will adhere to the Laurier University Policy for International Activities and this Safety Plan. I agree to complete and submit a Post-Activity Incident Report (Form 2) within two weeks of the completion of the Activity if any critical or non-critical incidents occurred during the conduct of the Activity.
_____________________________________ _______________________________ _______________________ Name and Title (Activity Leader) Signature Date
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I certify that this Risk Assessment and Safety Plan accurately describes the nature and scope of the International Activity, identifies the foreseeable hazards, and documents the plans that have been put in place to manage the associated risks. I affirm that I will ensure that, in accord with the Laurier University Policy for International Activies, the participants are appropriately briefed and have receiving appropriate training prior to participating in the activity.
_____________________________________ _______________________________ _______________________ Name and Title (Activity Coordinator) Signature Date
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I certify that I have reviewed and approved the above Risk Assessment and Safety Plan for the International Activity.
_____________________________________ ________________________________ _______________________ Name and Title (Department Director/ Chair) Signature Date
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Approved □ Denied □
_________________________________ ______________________________ ____________________________ Name and Title (Dean/VP) Signature Date
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Reviewed by Laurier International:
_________________________________ ______________________________ ___________________________ Manager, Programs and Services Signature Date |
· Once completed, a copy of this form is to be retained in the office of the Department Director/ Chair for a minimum of five years.
· Any completed Incident Reports (Form 2) are to be submitted to the Department Director/ Chair within two weeks of the completion of the International Activity.
