Business Services Form - Working in Isolation Checklist

This checklist is required to be filled out annually for any employee, student, or volunteer on campus that is performing a potentially dangerous task in an isolated environment under UWL's Working in Isolation Policy.


The Working in Isolation Checklist can be completed using the following form in DocuSign. Once you have filled out and signed the document. It will be sent to Business Services. A fully signed copy will be returned to the Supervisor for their records:

Required Attachment

The Job Hazard Analysis document is a required attachment to the checklist. Click on the link below and download the document to your computer to start filling it out. A separate analysis needs to be completed and attached to the checklist for each unique task that the individual is performing. 

Job Hazard Analysis


Information about the requirement in the Working in Isolation Checklist can be found in the Working in Isolation Policy:


The roles that will need to be entered in order to use the form are as follows:
Supervisor: Initiates the request and completes most of the fields on the form.
Business Services Record Keeper: Acknowledges Receipt of the Document and maintains a copy in Business Services.


Please contact Business Services at with any questions about using this form.

Form Layout

The form layout, along with the roles that complete each section of the form, are as follows. There will be a button on the DocuSign form that will allow you to attached the Job Hazard Analysis form:
WII-Form View

KeywordsIsolation, Working in Isolation, working   Doc ID123061
OwnerSpencer G.GroupUW-La Crosse
Created2022-12-14 17:44:29Updated2024-01-17 16:32:59
SitesUW-La Crosse
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