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Information Request Form for Scuba Diving and Snorkeling … ·  · 2018-04-18Title: Microsoft Word - Information Request Form for Scuba Diving and Snorkeling Activities.docx Created

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Page 1: Information Request Form for Scuba Diving and Snorkeling … ·  · 2018-04-18Title: Microsoft Word - Information Request Form for Scuba Diving and Snorkeling Activities.docx Created

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Information Request Form for Snorkeling or Scuba Diving Activities

This form should be completed by the IU project / activity leader no less than 30 days prior to planned scuba diving or snorkeling activities. The IU Diving Control Board’s designee, the Diving Safety Officer (DSO), will receive and review all scuba diving and snorkeling requests.

Please complete this application for review by the Diving Control Board.

Project/activity dates: _________________________________________________________________

Project/activity location: _______________________________________________________________

Project/activity IU Campus affiliation: ___________________________________________________

IU Department or program affiliation: ___________________________________________________

Project/activity Leader 1 Name: _________________________________________________________

Phone & Email: ________________________________________________________________

Diver certification rating/agency: _________________________________________________

Project/activity Leader 2 Name: _________________________________________________________

Phone & Email: ________________________________________________________________

Email: ________________________________________________________________________

Diver certification rating/agency: _________________________________________________

Please indicate the type and number of participants involved in scuba diving or snorkeling activities:

☐ Faculty / Staff (#_________) ☐ IU Student (#_________) ☐ Visitor (#_________)

Please briefly describe the scope of project or ativity (dives per day, total daily bottom time, etc.):

Page 2: Information Request Form for Scuba Diving and Snorkeling … ·  · 2018-04-18Title: Microsoft Word - Information Request Form for Scuba Diving and Snorkeling Activities.docx Created

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Please check all anticipated activities that apply: ☐ Scientific diving ☐ Recreational diving☐ Diver training ☐ Snorkeling (skin diving)

Anticipated depth ranges (feet) include: ☐ 0 – 60 ☐ 60 – 100 ☐ 100 – 130 ☐ 130 +

Please check all environmental conditions that apply:☐ Fresh water ☐ Salt water ☐ Shore Platform ☐ Boat Platform☐ Aquarium ☐ Swimming pool ☐ Cold water, < 70°F ☐ Other: ________________

Please check all specialized scuba diving activities that apply: ☐ Drift ☐ Altitude☐ Night

☐ Full-face mask ☐ Mixed gas (EANx) ☐ Semi-closed or Closed-circuit scuba☐ Overhead environment: wreck, cavern, cave, ice, etc. ☐ Hookah☐ Other: ____________________________________________________________________________

Dive planning mechanism: ☐ Dive Table & Timing Device ☐ Dive Computer ☐ N/A - Skin Diving

Please identify dive centers and/or charter operators that you plan to contract with.

1. Company Name: ________________________________________________________

Phone: _________________________________________________________________

Email and/or company website: _____________________________________________

2. Company Name: ________________________________________________________

Phone: _________________________________________________________________

Email and/or company website: _____________________________________________

Project/Activity Leader: ___________________________________ Date: ______________ Signature

Please return 30 days prior to project or activity start date to: Samuel I. Haskell, Diving Safety Officer University Environmental Health & Safety, Diving Safety Program 1025 E 7th Street, SPH 112J, Bloomington, IN 47405 Phone: (812) 856-5860 Email: [email protected]

For Office Use Only:

Date Received: _______________________ Date Reviewed: _______________________

Action Taken: ____________________________________________________________

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