Participant Safety Assessment Form
Complete this form to review participant readiness, note any safety concerns, and identify precautions before participation.
Participant Profile
Participant Name
*
First Name
Last Name
Role or Relation to the Event/Program
*
Age Group
*
Under 18
18-24
25-34
35-44
45-54
55+
Safety Screening
Planned activity or participation type
*
Please Select
Strength training
Cardio exercise
Team sport
Outdoor activity
Worksite task
Rehabilitation session
Educational session
Other
Current safety readiness level
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Mobility, environmental, or equipment concerns
*
Reduced mobility
Balance concerns
Poor visibility
Uneven terrain
Wet or slippery surfaces
Heavy equipment handling
Limited access or spacing
Temperature exposure
Other
Recent warning signs or issues to review before participation
*
None
Minor concern
Moderate concern
Immediate review needed
Precautions and Follow-Up
Precautions Needed for Safe Participation
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: