<p> T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A | Go Global V A N C O U V E R 1783 West Mall (International House) Vancouver, BC, V6T 1Z2 Tel: 604.822.0942 Fax: 604.822.9885 [email protected] www.students.ubc.ca/global</p><p>GROUP STUDY PROGRAMS SAFETY PLANNING RECORD</p><p>The purpose of this Record is to document the potential risks that students and faculty participating in a Group Study Program may encounter in the international location, and to create a plan for mitigating those risks. </p><p>This Record will form the basis for portions of the Health and Safety Pre-Departure Student workshops, and the Student Handbook for the Term Abroad Program. Our goal in planning ahead is to prepare students and faculty as fully as possible, thereby mitigating the risks they will encounter difficulties during the experience.</p><p>This form is to be completed by the Program Director as part of the approval process for the GSP.</p><p>Department(s)/Unit(s) involved in Group Study Program Program Director’s Name and Contact Information Names and departments/units of other Faculty members or Staff participating in project planning Off-campus Program Director (if different from above) Location(s) of Study Program and dates Country Geographical Site City (or nearest city) Date of Departure: Date of Return: </p><p>Please attach a complete travel itinerary (locations, dates)</p><p>Modes of Transportation: </p><p>Check all that apply</p><p>Private vehicles</p><p>Commercial Carriers (bus, plane, etc.) Other (please specify): </p><p>Chain of Responsible Leadership</p><p>List all those who have a leadership role (including alternates)</p><p>Name and Position Leadership role Trained First Aid? (Current) Other special training Yes/No</p><p>Number of Student Participants </p><p>Risk Assessment</p><p>List identified hazards associated with activities or environment (i.e., extreme heat or cold, high altitudes, disease, crime, violence, political instability, disease, etc.) and risk management measures planned or taken for eliminating or reducing risks to acceptable levels. Append additional pages as required.</p><p>Hazard Risk analysis Risk Management Plan</p><p>Travel Immunization/Prophylaxis Requirements</p><p>Check all that apply.</p><p>Diphtheria Rabies Hepatitis A Hepatitis B </p><p>Rubella Tetanus Malaria Typhoid Fever</p><p>Measles Yellow Fever Polio</p>