Forms

Email completed forms to risk@fhda.edu (preferred) or send via interoffice mail to the attention of Risk Management.

FORM TITLE	INTENDED PURPOSE
DMV Driver Record Release	Only Employees and Volunteers of Record who have been cleared through Risk Management are authorized to drive District vehicles. Complete the DMV Driver Record Release Form for authorization to drive a District vehicle, including Electric Carts, Gators, and similar types of vehicles. Submit this form at least one week before the first driving activity date with the District Approval Signature to allow for processing.
Ergonomic Evaluation Request	For ergonomic evaluations and minor workstation adjustments; employee must first complete a self-evaluation per the "Ergonomics Guide for Computer Workstations" available in MyPortal under the Employee Safety Resources tile.
Insurance Certificates	To request an insurance certificate for proof of coverage. Include a copy of the Contract Agreement when an Additional Insured endorsement is requested.
Fieldtrip/Excursion Request Form	To establish the proposed travel as an officially recognized college sponsored Activity (Completed by the Instructor/Advisor).
Fieldtrip/Excursion - Release of Liability and Assumption of Risk Form	To be completed by the Student/Participant and submitted to the Instructor/Advisor at least 10 days in advance of the proposed Fieldtrip/Excursion.
Non-Employee Injury Incident Report Form	The safety and security of our students and visitors is one of the District’s highest priorities. Please report injuries involving students or visitors as soon as possible using this Form.
Student Accident Insurance Claim Form	The District provides students with accident insurance through Mutual of Omaha Insurance Company. If a student is injured on campus or during District-sanctioned activities, use this form to file a claim for coverage. Please note that student accident insurance is secondary to the student's primary insurance. Follow the instrructions as indicated on the form.
Supervisor’s Claim & Safety Report of Accident	Supervisors must complete this form to report any workplace accidents or incidents involving employees. Once completed, please submit the form to mybenefits@fhda.edu. For incidents involving employee injuries, detailed information about seeking medical care is available at this link: https://hr.fhda.edu/benefits/_workers-comp.html. Contact the Human Resources department for additional questions.
Volunteer of Record	All Volunteers are required to complete a LiveScan criminal history background check through the District Police Department and must be approved by Risk Management prior to start of service. Volunteers can assist, but may not take the place of a faculty, staff, or union position; reference the attached VOR Process Flow Chart that describes the general process.
Voluntary Activity Waiver - Assumption of Risk and Release of Liability and Indemnity	This Voluntrary Activity Waiver is designed to inform and protect participants engaging in activities within the District. By signing this form, participants acknowledge and assume the inherent risks associated with the activity, thereby releasing the District from any liability for injuries or damages that may occur. It serves as a clear agreement between participants and the District, ensuring a mutual understanding of responsibilities and promoting safety during all activities.