Pre‐departurenotificationforoff‐campus
activitiesinurbanareas
This form should be lodged with the Head of academic/administrative unit or their nominated delegate prior to the trip commencing. All details should be supplied with the completed checklist Academic/AdministrativeUnit:___________________________________________________
Dateformcompleted:_________________________________
Off‐campusactivity:___________________________________________
Destination(s) (include map and references): _________________________________ Date(s): ___________________________ Participants
Note: The recommended staff/student ratio is 1:10 and a ratio of less than 1:20 is not advisable. Where possible, there must be male and female supervisors for activities involving male and female students. (If preferred, attach a list). Please indicate participant status (staff member, postgraduate, honours or undergraduate student, volunteer) ParticipantName
Participantstatus
ParticipantIDNumber
Safety Officer: _________________________________ QualifiedFirstAiders(nameandlevel)
Name
Level
_________________________________________________________________________________________________________________________________ Off‐campus Urban pre‐departure notification, v.2 Responsible Officer: Manager, OHS Page 1 of 2 Date of first issue: November 2013 Date of last review: February 2015 Date of next review: 2018 For the latest version of this document please go to: http://www.monash.edu.au/ohs AS/NZS 4801
OHSAS 18001 Communication
Phones (Make & model type): ________________________________________________________ Phone numbers: (1) ________________________ (2) ________________________ Tripdetails
Departure: Time: _________________ Date: ________________________ ProposedRoute:___________________________________________________________________
ETADestination: Time: _________________ Date: ________________________ ProposedReturnRoute:___________________________________________________________
ReturnETA: Time: _________________ Date: ________________________ Staffmember(s)incharge
Name: _______________________ Signature: _________________________ Date: ___________ Name: _______________________ Signature: _________________________ Date: ___________ _________________________________________________________________________________________________________________________________ Off‐campus Urban pre‐departure notification, v.2 Responsible Officer: Manager, OHS Page 2 of 2 Date of first issue: November 2013 Date of last review: February 2015 Date of next review: 2018 For the latest version of this document please go to: http://www.monash.edu.au/ohs