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Wilfrid Laurier University Leaf
October 24, 2014

Canadian Excellence

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.

  1. Submit completed form to the Department Director/ Chair.
  2. Any student or staff member organizing an individual trip must complete the form as Activity Coordinator.
  3. Department Director/ Chair must submit approved form to the appropriate Dean or VP for final approval.

Department ? ____________________________

Student Group ? __________________________

Individual: ? _____________________________

Activity Coordinator (Applicant and overseer of Activity. May or may not lead the Activity):

Name: __________________________________

Email:___________________________________

Phone:___________________________________

Purpose of International Activity:

? Academic: Undergraduate ____ Graduate ______

? Research ? Other extracurricular

International Activity Leader (if different fromC oordinator ):

Name: ___________________________________

Email: ___________________________________

Phone: ___________________________________

Nature of International Activity (include team name, course, etc. if :

Location of International Activity:

Country:

Geographical Site:

Nearest City (name, distance to):

Please attach a complete travel itinerary (location, dates, map if applicable)

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.

Date of Departure:

Date of Return:

Chain of Responsible Leadership:

List all those who have a leadership role

CATEGORY (Check all that apply)

Team Leader

Other (specify)

Trained First Aider

NUMBER OF Participants (other than the leadership team listed above): ________

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.

Hazard Identification

Risk Analysis

Risk-Management Plan

1.

2.

3.

4.

5.

6.

7.

8.


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

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

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

Approved ? Denied ?

_________________________________ ______________________________ ____________________________

Name and Title (Dean/VP) Signature Date

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.