Safety Officer Application
This is the new one stop shop for becoming a Safety Officer. Please fill out all required fields in order for your application to be reviewed by the Sport Club Office. You will receive an email with a link to view the Google Sheet summary of applications. Your application, once reviewed, will be shaded green if approved and red if denied. If you have questions about submitting this application please contact the Sport Club Office at 757-221-2959.
Email address *
First and Last Name *
Phone Number *
Club(s) *
Safety Officer Responsibilities
Each Club must designate AT LEAST two Safety Officers, but may have more. In order to be a Safety Officer, you must read and agree to the conditions below. Place a check in each box to indicate that you have read and understand each condition.
I will ensure that our club's First Aid Kit is fully stocked at all times (kits may be re-stocked during regular building hours in the downstairs equipment room of the Rec Center - to ensure someone will be available to unlock the cabinet, please coordinate with the sport club office). *
Required
I will complete and submit to the Sport Club Office an Injury / Incident form (Form I) anytime an injury occurs during club activity. *
Required
I will ensure that Campus Recreation is contacted ANY TIME an ambulance / EMT is summoned to care for or check on an injured club member or if a club member is taken to the hospital as a result of an injury sustained during club activity (whether at home or away). *
Required
I will ensure that the Campus Recreation Emergency Protocol (Form E) is on-hand for quick reference at all club activities / events. *
Required
I will ensure that all outdoor activity stops and club members seek shelter indoors if a thunder / lightning storm is approaching. I will then allow 30 minutes after the last sound of thunder or flash of lightning before resuming club activity. *
Required
Additional Safety Protocols
The Department of Campus Recreation provides general Accident/Injury guidelines for clubs on Form E. Because each club operates within varying parameters (i.e. Sailing Club on water, Outdoors Club in backcountry), it may be necessary for your club to provide additional safety protocols.
If your primary club has any additional safety protocols, please list them:
If your secondary club has any additional safety protocols, please list them:
Safety Officer Quiz
If your application is denied due to a failed Safety Officer Quiz score, you will be contacted with instructions to retake the quiz on this application.
1. As a Safety Officer, it is necessary to submit injury reports for both home and away activities. *
1 point
2. Individuals with First Aid and/or CPR certifications may diagnose an injury if it is known what is wrong with the injured club member. *
1 point
3. Select all injuries that would require a Safety Officer to submit an injury report: *
5 points
Required
4. CPR is a combination of: *
1 point
5. Situation: Only ONE First Aid/CPR certified Safety Officer is present at practice, but the club members still want to hold practice. What can you do to remain in compliance with the Safety Officer requirements? *
1 point
6. What's necessary to return to play after suffering a concussion? *
1 point
7. A person is unconscious. Put the following steps that should be taken in the correct order:
A. Tap the person and shout
B. Open Airway
C. Check for signs of life (movement and normal breathing)
D. Check the scene for safety
List steps in order from left to right, in caps, with commas separating each letter below (example: X, Y, Z). *
1 point
8. Situation: While practicing two players collide and one gets an elbow to the head. You run out onto the field and see that the player is holding his head. After asking the player you find that he is dizzy, his head hurts, and confused. Assuming he has suffered a concussion, based on this information, what do you do as the club safety officer? Check all that apply. *
6 points
Required
9. When is it necessary to activate the Emergency Contact Protocol? *
1 point
10. Situation: During a game off campus a participant breaks their arm. What do you do as the club safety officer? Check all that apply. *
5 points
Required
Please upload your CPR/First Aid Certifications (you may include EMT, WFA, WFR, etc.). *
Required
Statement of Understanding
The Department of Campus Recreation provides general Accident/Injury guidelines for clubs on Form E. Because each club operates within varying parameters (i.e. Sailing Club on water, Outdoors Club in backcountry), it may be necessary for your club to provide additional safety protocols. Please place your signature below indicating that you understand and agree to all responsibilities that are associated with being a Safety Officer.
Online Signature (Legal Name) *
Date *
MM
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DD
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YYYY
A copy of your responses will be emailed to the address you provided.
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