Forms and Checklists
WAIVERS AND AUTHORIZATION FORMS
SIA recommends that districts use the following forms available in English, Spanish, Russian, Ukrainian, Hmong, Hindi, Punjabi, Tagalog and Vietnamese. These forms have been formatted with space at the top to allow for printing on district letterhead. The purpose and use guideline is provided for each of the available forms.
Purpose and use guidelines for Waivers and Authorization Forms - descriptions
PDF DocumentDownload Waivers and Authorization Forms "Cheat Sheet" (pdf)
Use of Facilities Forms
- Use of Facilities, Indemnity and Insurance Agreement (Education Code)
- Use of Facilities, Indemnity and Insurance Agreement (Non-Education Code)
- Use of Facilities Agreement Between Public Agencies
Participation Forms
- PDF DocumentSports-Related Form "Cheat Sheet" (pdf)
- Agreement for Activity Participation
- Contract for Adult Activity Participation
- Agreement for Team Participation
- Sports Physical Examination Form
- Student Field Trip Authorization
- Student Field Trip (Outside California) Authorization
Transportation Forms
- Volunteer Personal Automobile Use Form
- Student Personal Automobile Use Form
- Student Alternate Transportation Form
AMERICANS WITH DISABILITIES ACT (ADA)
- ADA Public Notice for District Website (Updated 5-9-13) Word DocumentDownload Template
- ADA Public Notice website template (doc)
COMPLIANCE
Injury and lllness Prevention Program
- Appendix C – Sample Safety and Health Policy Statement Word DocumentDownload Sample IIPP Policy Statement (doc)
- Appendix D – Monthly Property Checklist Monthly Property Checklist (doc)
- Appendix E – Hazard Alert Form Word DocumentDownload Hazard Alert Form (doc)
- Appendix H – Safety Meetings Word DocumentDownload Safety Meeting Form (doc)
- Appendix J – Accident Investigation Report Word DocumentDownload Accident Investigation Form (doc)
Stormwater
Word DocumentChecklist for 2018-2019 monitoring year
Excel DocumentWet-Weather Storm Water Inspection Report Form. (Use this form when collecting your samples)
Excel DocumentMonthly Non-Storm Water Discharge Inspection Report Form. (Use this form to record your monthly visual observations)
DRIVING SAFETY
SPAB Checklist PDF DocumentDownload SPAB Checklist (pdf)
What Employers Need to Know About DOT Drug and Alcohol Testing
FIRE SAFETY AND ARSON PREVENTION
Arson Prevention Tips Checklist Word DocumentDownload Arson Prevention Checklist (doc)
HEALTH AND WELLNESS
Golden Carrot Fund
- Golden Carrot Fund Request Form Word DocumentDownload Golden Carrot Form (doc)
- Golden Carrot Fund Prevention Project/ Activity Evaluation Word DocumentDownload Project Evaluation Form (doc)
CPR Posters
- Steps for Choking Emergencies PDF DocumentChoking poster
PLAYGROUND SAFETY
- Download Playground Audit Checklist (docx)
- Download Playground Routine Inspection Form - Loose Fill Surface Material (doc)
Download Playground Routine Inspection Form – Unitary Surface Material (doc)
Playground Signage
School playgrounds are often available for use by the public during non-school hours. These labels were designed to help the public use your equipment safely. The labels indicate the appropriate age range of the user, suggestions for safe play and direction for adult supervision and concerns. Each label is 5x7 inches and can be affixed directly onto the equipment. There are three age range options 2 to 5 years, 5 to 12 years and 2 to 12 years. Select the label that is most appropriate for the design of your equipment.
Playground Label Order Form (pdf)
Resources
uuWord DocumentPlayground Audit/Inspection form
SCHOOL, EMPLOYEE AND WORKPLACE SAFETY
- Swimming Pool Safety & Compliance Checklist PDF DocumentDownload Pool Safety Checklist (pdf)
- Appendix C – Sample Safety and Health Policy Statement Word DocumentDownload Sample IIPP Policy Statement (doc)
- Appendix D – Monthly Property Checklist Property Checklist
- Appendix E – Hazard Alert Form Word DocumentDownload Hazard Alert Form (doc)
- Appendix H – Safety Meetings Word DocumentDownload Safety Meetings Form (doc)
- Appendix J – Accident Investigation Report Word DocumentDownload Accident Investigation Form (doc)
Warning Labels
The following Warning Labels are available upon email request to Prevention Services. Be sure to indicate the specific label you are interested in.
- "Do Not Remove Paperguard from this Papercutter"
- "AV Cart Tipover Hazard"
- "Folding Table Tipover Hazard" (1 1/2" x 10")
- "Warning! Alarm System Electronically Protected" 4" x 4" (specify front adhesive or back adhesive)
- Tall Fire Extinguisher "Do Not Block" for interior (4" x 15")
- Square "Fire Extinguisher Inside" for exterior (5" x 5")
- Electrical Panel, Maintain 36" Clearance (7" x 7")
- Metal Ladder, Electrical Shock Warning (4-1/2" x 3")
- Step Ladder Safety (2" x 11")
- Ladder, "Danger Do Not Stand Above This Rung..." (6" x 1-1/2")
- "NOTICE This Property is Protected by Video Surveillance" (7" x 7") (specifiy front adhesive or back adhesive)
- SIA Playground Signage (5" x 7")
- Always Anchor Goals (3.5" x 3.5")
- Warning - Never Climb on Goal (3" x 6")
Sample Labels: Ladder labels / Cafeteria table labels / Soccer Goal labels / Other labels
Word DocumentDownload Warning Labels Form (pdf)
Email to Request Warning Label