Faculty of Engineering and Applied Science
Queen's University
Field Trip Safety Agreement Form
COURSE:
FACULTY SUPERVISOR:
LOCATION:
DATE:
{Course # and Name}
{Instructor Name}
{Client, Physical Address}
{Date of Travel}Note: if multiple trips planned, please
complete Section 8 below.
The use of this policy confirms that the trip proposed has been deemed as “low/manageable risk”, in accordance
with the Queen’s Safety Policy, as authorized by the Faculty Supervisor.
By signing this form, I agree that, as a representative of Queen’s University and the Faculty of Engineering and
Applied Science, and in the interest of providing the safest possible opportunity for myself and my project team, I
will abide by the requirements below:
1.
I acknowledge that, by participating in the field trip indicated above, I am assuming risks not significantly
greater than those encountered in every day life. I understand that the main purpose of this trip is to:
 Visit an industrial client facility to participate in a business meeting
 Visit an industrial client facility to participate in a facility tour
 Other – please describe:________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I realize that there are potential hazards that may exist with any off campus activity. To manage these
possible hazards and risks, I agree to remain with my industry client host at all times and to strictly obey all
instructions given to me by my team supervisor and/or by site staff regarding my behaviour while on site.
2.
Should I enter a work site area of the facility, I agree to bring with me and to wear CSA-approved safety
shoes/boots where required; I also agree to wear any additional personal protective equipment provided by
the site staff at all times while on site. I agree to obey any other safety requirements as specified by site
staff.
3.
I am familiar with the Queen's University code of conduct and I agree to conduct myself in accordance with
the code at all times. I will behave at all times with all due respect to my hosts, and I will follow all
directions from our hosts as they relate to my safety and well-being. In particular, a number of specific
requirements related to this site are as follows:
 The site is a {factory, office building, manufacturing plant, etc.}, and I will therefore not bring
food or drinks on site. Further I will not touch anything unless it has been indicated that it is safe
to do so by the site staff.
 In moving between various areas of the work site, it may be necessary to go through cramped
spaces and up temporary ladders to reach certain destinations; as such I agree that I am fit and able
to undertake these travels.
 Under no circumstances will I agree to enter into an activity or onto a site that I feel will endanger
me in any way.
4.
I will travel to and from the destination with the utmost care and caution for myself and my team. I
recognize the inherent risk in travelling on roads and highways in an automobile and will, at all times,
exercise safe practices and defensive driving strategies as expected by the laws of the province/country in
which I will be travelling. If I am driving, I further attest to the fact that I am legally eligible to drive a
vehicle in the province/country in which I am travelling.
I will travel with a mobile phone and am aware that I should contact the Queen’s Emergency Report Centre
(613 633-6111) in the event of an emergency or 911 in the case of an automobile accident.
5.
I will not consume alcohol and/or illegal drugs before or during off-campus activities, nor will I operate a
vehicle if feeling physically unfit to perform this activity at the legal acceptable ability.
6.
I will ensure that I have adequately prepared for weather and health risks prior to and during travel by
keeping constantly aware and up-to-date with current information or immediate surroundings and
circumstances. In the case of moderate to severe weather, particularly freezing rain, snow or high winds, I
agree to postpone departure or return until such time as the safety concern has passed and travel can take
place with minimal risk.
7.
By signing this form, I further agree to complete all post activity reporting as required in the event of
a critical or non-critical incident, per the following definitions:

8.
A non-critical incident is defined as damage or potential damage to the health, safety, or property of
one or more of the activity participants.
 A critical incident is defined as including but not limited to, serious illness/injury, fatal accidents,
sudden deaths, suicide, hate crimes, assaults or violent occurrences, political or civil unrest, natural or
environmental disasters
I will be visiting the above mentioned client and/or facilities for this same purpose and under the same
parameters several times over the period of {start date to end date}. This agreement will remain in effect
for all of these trips UNLESS there is a change to purpose/location/activity/length of stay for any one visit.
In these cases, a new form will be completed. I agree that I will consult my Instructor/Supervisor for
permission to travel off-site in advance of EVERY occasion.
Should either a non-critical or critical incident occur at any time during the course of the off-campus
activity, I will complete the Queen’s Off Campus Safety Policy Form 3.
Name
Student #
Signature
FACULTY SUPERVISOR: __________________________________
(Signature)
Date