Business Services Form - Working in Isolation Checklist
This checklist is required to be filled out 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.
Form
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.
Policy
Information about the requirement in the Working in Isolation Checklist can be found in the Working in Isolation Policy:
Roles
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.
Questions
Please contact Business Services at businessservices@uwlax.edu 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:
Alternative Fillable PDF Form
If the DocuSign form cannot be used, the form can also be submitted as a fillable PDF: