Information Request Form for Scuba Diving and Snorkeling Microsoft Word - Information Request Form for Scuba Diving and Snorkeling Created Date: 20160224151201Z

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1 Information Request Form for Snorkeling or Scuba Diving ActivitiesThis 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 Boards 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.): 2 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, < 70F 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 DivingPlease 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: sihaskel@indiana.eduFor Office Use Only: Date Received: _______________________ Date Reviewed: _______________________ Action Taken: ____________________________________________________________ Photography / VideographyProjectactivity dates: Projectactivity location: Projectactivity IU Campus affiliation: IU Department or program affiliation: Projectactivity Leader 1 Name: Phone Email: Diver certification ratingagency: Projectactivity Leader 2 Name: Phone Email_2: Email: Diver certification ratingagency_2: Faculty Staff: IU Student: Visitor: Email andor company website: Email andor company website_2: ProjectActivity Leader: Date: Date Reviewed: Action Taken: Company Name: Phone: 0 - 60: Other specialized activities: Faculty - Staff: Student: Visitor Box: Project Scope: 60 - 100: Snorkeling: Recreational diving: Scientific Diving: Diver training: 100-130: 130: Date Received: Night: Full-face mask: Hookah: Salt water: Fresh Water: Shore Platform: Boat Platform: Swimming pool: Other environment: Mixed gases: Drift: Aquarium: Cold Water environmental: Dive Table: Dive Computer: N/A Skin Diving: Overhead environment: Other environment text: Other activities: Semi-closed: Altitude: Photo / Video: Phone Part 2: Company Name Part 2: