Schedule B – Fieldwork Travel Checklist - Domestic
Fieldwork Leader to complete Schedule B in consultation with the staff member/student prior to
the fieldwork being approved.
Step 1: Minimum Precautions Checklist
For Travel/Fieldwork where all planned activities outlined in this application are being undertaken in
regulated and safe environments We/I (Curtin Staff / student) have read the Curtin University’s "Fieldwork Safety Guidelines" and
can confirm that all of the planned activities outlined in this application are being undertaken in regulated
and safe environments. (Please ensure list of participants is attached to Schedule A if group fieldwork)
A detailed fieldwork Health & Safety Risk Assessment has been completed below (go to Schedule
C).
We/I have notified my supervisor of any pre-medical conditions, and obtained a “Fit to Travel/Fly”
and will manage the rigours of the particular travel certificate from my treating physician along with
medications. We/I will provide a written action plan before we/I leave. (Where more than 1 participant, Fit
to Travel/Fly certificates attached)
Step 2: Checklist for Insurance and Emergency Assistance
We/I am a Curtin staff/student and we/ I have confirmed with the school’s travel coordinator that
we/I are covered by Curtin’s Corporate Travel Insurance Policy".
*Students: please note that in the case of medical emergencies etc., you must first approach
Medicare or your private health fund for reimbursement. Should you incur any out of pocket
expenses, please contact the Risk Management office on ph: 9266 3748.
Step 3: Declaration by Person Travelling/Fieldwork Leader for Group Fieldwork
We/I declare that we/I have read, understood and have signed off the “Conditions of Participation Form”
(Students) and the “Conditions of Participation Agreement” (Staff Members) prior to commencing this
fieldwork. Additionally, all information contained within this and the attached documents is true and correct
at the time of signing this form.
Signed:
Date:
Signed:
Date:
Signed:
Date:
Signed:
Date:
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Step 4: Fieldwork Leader to Complete
Date
Primary Checklist
Participants have or will be briefed on the details of the fieldwork and all relevant
safety policies, procedures and codes of conduct whilst on fieldwork
All equipment, vehicles and tools will be checked for safe operation prior to the fieldwork
I have made all necessary arrangements for the effective management of emergencies
that may arise in the course of the fieldwork
I have checked with participant/s that they have disclosed any medical conditions that
may affect their ability to safely undertake the proposed fieldwork
I have ensured adequate recovery time before return to work to ensure fitness for work has
been allocated to participants
Step 5: Approvals
Position
Signature
Date
Fieldwork Leader:
……………………………………………………………..
……………….
Head of Area:
……………………………………………………………..
……………….
Only required for HIGH/
EXTREME rating PVC OR DVC:
……………………………………………………………..
……………….
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Schedule B – Fieldwork Travel Checklist - International
For Travel/Fieldwork where the planned activities outlined in this application are being undertaken in
unfamiliar and/or remote environments and/or where the type and scope of regulation of hazards is
limited or unknown.
Steps 1-5 in Schedule B and Schedule C – Fieldwork Health and Safety Risk Assessment and other
listed attachments must be completed by the staff member/student in consultation with the Fieldwork
Leader prior to approvals being sought.
Step 1: Type of Destination/s
Into which category does your destination/s fit (please consult (http://smartraveller.gov.au/) to verify your
selection)?
1. For travel/fieldwork to/in destinations for which the advice is “DFAT 4 - Do not Travel”, the
University generally advises against all travel, consider alternative means to conduct the
research/activity. Please contact Risk Management for advice and the completion of relevant
documentation.
2. For travel/fieldwork to/in destinations for which the advice is “DFAT 3 - Reconsider Your
Need to Travel”, the University generally advises that alternative means to conduct the
research/activity be considered. Please contact Risk Management for advice and the completion of
relevant documentation.
Have alternative means for the conduct of the research/activity been considered?
YES
NO
If no, please explain briefly why?
If you are to travel to a DFAT 3 or 4 destination you, must complete Travel Risk Assessment in consultation
with Risk Management. The DFAT 4 Risk Assessment can be found at:
http://riskmanagement.curtin.edu.au/forms/index.cfm
3. For travel/fieldwork to/in destinations for which the advice is “DFAT 2 - High Degree of
Caution”, or “DFAT 1 – Exercise Normal Safety Precautions”, step 2 : Minimum Precautions
Checklist, and Schedule C – Health & Safety Risk Assessment must be completed.
Step 2: Minimum Precautions Checklist
a) Notification has been made and Travel advice sought from http://smartraveller.gov.au/
NO
YES
b) Australian Embassy, High Commission or Consulate contact details in destination/s have
been recorded and retained by the relevant School/Department or Office.
YES
NO
A detailed fieldwork Health & Safety Risk Assessment has been completed below (go to
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Schedule C).
We/I have notified my supervisor of any pre-medical conditions, and obtained a “Fit to Travel/Fly”
and will manage the rigours of the particular travel certificate from my treating physician along
with medications. We/I will provide a written action plan before We/I leave. (Where more than 1
participant, Fit to Travel/Fly certificates attached)
Step 3: Checklist for Insurance and Emergency Assistance
We/I am a Curtin staff /student and we/I have confirmed with the school’s travel coordinator that
we/I am covered by Curtin’s Corporate Travel Insurance Policy" .
Please note that the CUSTOMER CARE Emergency Number is +61 2 8907 5686 (reverse charge call
from anywhere in the world) and quote the Curtin Membership number: CC110CUR.
Step 4: Checklist Declaration by Person Travelling/Fieldwork Leader for Group Fieldwork
We/I declare that I have read, understood and have signed off the “Conditions of Participation Form”
(Students) and the “Conditions of Participation Agreement” (Staff Members) prior to commencing this
fieldwork. Additionally, all information contained within this and the attached documents is true and
correct at the time of signing this form.
Signed:
………………
Date
Signed:
………………
Date
Signed:
………………
Date
Signed:
………………
Date
Step 5: Fieldwork Leader to Complete
Date
Primary Checklist
Participants have or will be briefed on the details of the fieldwork and all relevant
safety policies, procedures and codes of conduct whilst on fieldwork
All equipment, vehicles and tools will be checked for safe operation prior to the fieldwork
I have made all necessary arrangements for the effective management of emergencies
that may arise in the course of the fieldwork
I have checked with participant/s that they have disclosed any medical conditions that
may affect their ability to safely undertake the proposed fieldwork
I have ensured adequate recovery time before return to work to ensure fitness for work has
been allocated to participants
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Step 6: Approvals
Position
Signature
Date
Fieldwork Leader:
……………………………………………………………..
……………….
Head of Area:
……………………………………………………………..
……………….
……………………………………………………………..
……………….
……………………………………………………………..
……………….
For DFAT 3 or HIGH/
EXTREME Risk Rating
PVC or DVC:
For DFAT 4 only VC:
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