FIELD TRIP/PROJECT SAFETY TRAINING DOCUMENTATION (SIGN-UP SHEET)

TRIP/PROJECT LEADER CERTIFICATION

I Certify that I presented the applicable safety and health information to the participants of this field exercise as outlined in the current CNSM Field Trip/Project Safety Manual (available from CNSM Safety Website http://www.cnsm.csulb.edu/services/safety/index.htm). I will give this sign-up sheet to the Department Office and bring a copy with me on the field exercise.

FIELD TRIP/PROJECT LEADER NAME: ________________________ SIGNATURE: ________________________ DATE: ___________________

TRIP/PROJECT DESCRIPTION: _________________________________________________________________________________________________

PARTICIPANT CERTIFICATION

I hereby acknowledge that I have been instructed in field trip/project rules and guidelines according to the CNSM Field Trip/Project Safety Manual, including participant responsibilities, vehicular requirements, and safety guidelines and specific rules for field operations, etc. I hereby agree to participate in full accordance with the safety instructions provided. I further agree that I will not undertake any specific tasks without appropriate instruction, supervision and understanding of the potential hazards involved. I understand that unpaid participants are responsible for their own medical treatment costs if injured during a field exercise and that paid participants must follow Workers Compensation “industrial accident” procedures.

PRINT NAME

SIGNATURE

Emergency Contact Name

Emergency Contact Phone

FieldTripSignup.Emp.6.05.doc