Working in Isolation Notification Form

Information on Identified High-Hazard Activities and Working in Isolation can be found here.

This document serves as notification that the individual identified below will be completing work in isolation as defined by UW System Policy 620 which is prohibited without approval by a supervisor. Each individual who will be completing high-hazard activities while working in isolation must be identified on a separate notification form.

Working in Isolation Notification Form

Permission is granted to (Name of Employee/Researcher/Student):

The above individual will be completing the following activity which has been deemed a high hazard activity subject to System Policy 620 – Working in Isolation.

Detailed and documented description of activity and risk mitigation strategies that will be enacted as described in System Policy 620

This work is reoccuring

yes

The work is approved on:

This work will be completed on:

Supervisor's Name

First Last

Supervisor's Department

Supervisor's Email

Supervisor's Phone Number

Departmental Supervisor

First Last

Departmental Supervisor's Email

Departmental Supervisor's Phone

Comments

This field is for validation purposes and should be left unchanged.