DSO use only
Plan ID:________
Begins: _________
Expires: _________
Penn State Diving Safety
(6 month maximum)
Appendix 15 - Application for Approval of Dive Plan
Date:____________________________________
For:_______________________________________
PI/Project Supervisor:_______________________
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) List of Dive Team
Members. Name, lead, level, authorization depth, expiration date, capacity and contact.
Diver Name (Last, First)
-
Lead
Level
Auth. Depth
-
-----------------------------------------
-
EAN
DC
Exp. Date
Employment Capacity *
-
-----------
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 Plan
Risk Event
Prob. Of
Occurrence
Severity of
Consequences
Nature of
Consequences
Mediation to be Employed
-
-----------
-----------
x
x
-
-----------
-----------
x
x
-
-----------
-----------
x
x
-
-----------
-----------
x
x
-
-----------
-----------
x
x
-
-----------
-----------
x
x
Emergency Oxygen On Site? No
First Aid Kit On Site? No
Emergency Contacts
Separate Vessel Captain? No
Surface Tender On Site? No
Please supply individual Emergency Management Plans for all islands included in Dive Plan, See EMP form.
Agency: (Closest to the
Site)
Location of On
Site
Est. Response
(miles)
Est. Response
Time
Respond Via
Contact Via
Coast Guard
-
-
-
-
-
Rescue/EMT
-
-
-
-
-
Closest Hospital
-
-
-
-
-
Hyperbaric
Treatment Center
-
-
-
-
-
Additional Comments/Considerations:
DSO Email: tsw113@psu.edu
Penn State Diving Safety
Project Title:
PI:
Dive Plan Begin Date:
Date:
Plan ID:
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:
___________________________________
___________________________________________
Signature, DSO
Signature, DCB Chair
Date
Date
Please review all Diving Safety Program remarks, conditions and/or restrictions and return to PSUDP.
X_________________________________________________________________
Signature of PI, Advisor, Supervisor or Lead upon review
DSP Email: tsw113@psu.edu
______________________________
Date