Safety Forms

• Event Approval Forms & Instruction
• Event Policy, Alcohol & UND Waivers
• Minors on Campus Policy & Forms (in Vector Solutions for UND Employees)
• Facilities Use Agreement Template

Incidents Involving People

• Incident Reporting Form - People (Employee/Student/Visitor)
• Incident Investigation Form
• Witness Statement

Incidents Involving UND/State Non-Vehicle Property

• Incident Reporting Form - Property
• Incident Investigation Form
• Witness Statement

Incidents Involving State Fleet / Leased / Rental Vehicles

• UND Motor Vehicle Report
• Incident Investigation Form

Other Incidents

• Work Comp Claims Management Checklist for Supervisors
• Sharps Injury Reporting Form
• Fire Call Report Form

DMP Program Procedures

UND participates in the Risk Management Workers Compensation Program. This allows the Risk Management Workers Compensation Program (RMWCP) to designate health care providers to treat your workplace injuries and illnesses. Workforce Safety and Insurance may not pay for medical treatment to another provider unless you are referred to this provider by the designated medical provider, or unless you notified us in writing prior to the injury that you wanted to be treated by a different medical provider. If you need to seek medical attention due to a work-related injury, you must see a designated medical provider (DMP). Emergency care is exempt from this designated provider requirement. The UND Designated Medical Provider (DMP) form has a listing of all UND designated medical provider areas.

Altru Occupational Health/Employer Health Solutions has been selected for the Grand Forks Area as it has an occupational health services department with an occupational health physician as the attending physician. An occupational health physician specializes in work-related injuries/illnesses. 

UND Student Health Services is not a designated medical provider for the University.  

Employees intending to see a medical provider other than the University’s DMP must designate this in writing on the DMP form. The form must be on file at the Office of Safety prior to the work-related injury. This includes not only physicians, but chiropractors, dentists, optometrists/ophthalmologists, etc.

If your job should require you to be out-of-town for a short period, you are urged to seek an After-Hour Clinic or an Urgent Care/Emergency facility. Additionally, if your job will require you to be away from North Dakota for more than 28 days whether out-of-state or overseas, you must fill out the Out-of-State Workers Compensation Coverage Form or the Travel Outside the U.S. Form and the Notification of Out-of-Country form and submit to the Office of Safety at Stop 9031 or e-mail them to: UND.safety@UND.edu. 

If you do not have a DMP on file or need to update your DMP, please fill out the attached form and submit to the Office of Safety. If updating the DMP form, please fill it out with all the medical providers you wish to utilize because the Office of Safety removes the previous and replaces it with the new DMP.

 If you have any questions about the designated medical provider policy, please contact the Office of Safety at 701.777.3341.

Designated Medical Provider (DMP) Form

• Out of State Workers Compensation Coverage Memo
• Out of State Workers Compensation Coverage Form

• International Travel -  Outside the U.S. Travel
• Notification of Out-of-Country Workers Compensation Coverage
• Employee Work-Related Travel Policy Coverage Information

• Volunteer Workers Compensation Memo
• Volunteer Form Instructions
• Volunteer Workers Compensation Form
• Volunteer Waiver

• Departmental AED Request Form
• AED Monthly Tracking Sheet

Duress Alarm Request Form

North Dakota Workforce Safety and Insurance

• Domestic-International Student Field Trip Form - to be completed by UND sponsoring department
• UND Waiver (Field trip) - Each student shall sign a waiver prior to departure.  The sponsoring department retains the signed waiver for record keeping.
• UND Waiver (Field trip with free time)

• UND Waiver
• UND Participation Waiver (Under 18 years of age)
• UND Waiver (Field trip)
• UND Waiver (Field trip with free time)

Departmental Building and Property Loss Report - for FM use only

• University Property/Equipment Check-out Form (Employee/Department)
• University Property/Equipment Check-out Form (Off Campus)
• University Property/Equipment Check-out Form (Students)

Surveillance Equipment Request Form (240a)

The purpose of the Surveillance Equipment Standard Practice (240a) is to regulate the use of Surveillance Equipment for the purpose of security. This applies to all personnel, schools, and centers of the University in the use of surveillance equipment. This Standard Practice is not intended to cover the use of Web cams unless the Web cam is used for surveillance.

• Fire Drill Evaluation Form
• Fire Extinguisher Training Handout
• Fire Extinguisher Monthly Inspection Checklist

• Appendix A - Animal Exposure Risk Assessment
• Appendix B - Health Risk Assessment
• Appendix C - Medical Surveillance Questionnaire
• Appendix D - MP Health Assessment & Declination
• Appendix E - OHP Annual Notification

• CSA Crime Reporting Form
• Sexual Assault Form
• Report a Crime (Anonymous)

• Application for Authorization to Possess & Use Radioactive Material
• Application for Authorization to Possess & Use Radiation Producing Machines
• Radioactive Material Requisition Form
• Radioisotope Receiving Form
• Radioactive Waste Disposal Form
• Decontamination of Equipment Form
• Radiation Badge Request Form
• Radioactive Material Users Information Form

Contractor/Working Visitor Form

• Workers Compensation Process
• Hazard Communication
• UND Training Record