DSO use only
Plan ID:________
Begins: __________
Expires: _________
Penn State Diving Safety
(6 month maximum)
APPENDIX 15
Application for Approval of Dive Plan
Date:____________________________________
PI/Project Supervisor:_______________________
For:___________________________________________________
PI/Project Supervisor Title:________________________________
Project Title:
____________________________________________________________________________________________________
__________________________________________________________________________________________________
Department: ______________________________
Phone:__________________________________________________
Address: _________________________________
Email:__________________________________________________
_________________________________
Fax: ___________________________________________________
Dive Plan Purpose:_________________________
List of Dive Team Members: (Continue on separate sheet if needed, see DTM form)
Lead
Diver Name (Last, First)
Level
Auth. Depth
EAN
DC
Exp. Date
Employment Capacity *
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--
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--
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--
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Diver Contact
*E=Employee; V=Official Volunteer; N=Uncompensated Non-Employee
Dive Locations:
Brief Description of Activity (continue on separate sheet if needed):
Maximum Planned Depth_________________ Dives Per Day_____________ Total Daily Bottom Time: __________min.
Diving Mode (Life Support): Open Circuit
---------------------- Breathing Gas: Air
--------------Dive Tables to be used: Naui
---------------------------- Dive Computers (where authorized): No____________
Will Any Planned Profiles Entail Decompression Stops, Other Than Safety Stops: No______________________________
Environment:
----------------------------Platform: Shore
--------------Source of Breathing Gas:______________________________________________________________________________
Type of Vessel:___________________________________ Source of Vessel:____________________________________
Special Equipment Considerations:
Please return Dive Plan Application forms to: Tim White, Diving Safety Officer
Diving Safety Program, Penn State, Phone: (814) 865-2213, DSO Email: tsw113@psu.edu
Penn State Diving Safety
Project Title:
PI:
Date:
Emergency Management Plan
Site/Location:_______________________________________________________________________________
Risk Management Assessment:
Prob. Of
Occurrence
Risk Event
Severity of
Consequences
-----------
-----------
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-----------
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Nature of
Consequences
Mediation to be Employed
Emergency Oxygen On Site? No
Separate Vessel Captain? No
First Aid Kit On Site? No
Surface Tender On Site? No
Emergency Contacts Please supply individual Emergency Management Plans for all islands included in Dive Plan, See EMP form.
Agency: (Closest to the Site)
Location or On Site
Coast Guard
Rescue/EMT
Closest Hospital
Hyperbaric
Treatment Center
Additional Comments/Considerations:
DSO Email: tsw113@psu.edu
Est. Response
(miles)
Est. Response
Time
Respond Via
Contact Via
Penn State Diving Safety
Project Title:
PI:
Date:
Plan ID:
Dive Plan Begin Date:
End Date:
Lead Diver’s Affidavit:
I agree to follow all PSU diving regulations, and applicable State and Federal law while conducting these operations.
X____________________________________________
Signature of Lead Diver
________________________
Date
Supervisor, Advisor or PI’s Affidavit:
I agree to ensure compliance with Penn State diving regulations, and applicable State and Federal law during conduct of these operations.
I verify that the employment status of listed divers for this project is as indicated.
X____________________________________________
_______________________
Date
For Diving Safety Program use only. DO NOT WRITE BELOW THIS LINE
Receipt Date:
SDP ACTION:
DSO Review Date:
--------------------------------------
Remarks, Conditions or Restrictions:
Please review all Diving Safety Program remarks, conditions and/or restrictions and return to PSU DSO.
X_________________________________________________________________
Signature of PI, Advisor, Supervisor or Lead upon review
___________________________________
Signature, DSO
Date
____________________________
Date
Email: tsw113@psu.edu
___________________________________________
Signature, DCB Chair
Date