Insurance and Risk Forms

Academic Field Trip Forms:

Academic Field Trip Waiver of Liability and Hold Harmless Agreement

To be completed by all student participants before departing on a University sponsored field trip.

Academic Field Trip Participant List

To be completed by faculty to record all student participants' emergency contact information before departing on a University sponsored field trip.

Acknowledgement & Verification for University and Private Vehicles

Completed by employee or volunteer verifying their understanding of the University's policies regarding vehicular use.

Air Travel Voluntary Participation

This is the initial notification by the University (President or Designee) to any student, prior to undertaking California State University-affiliated air travel, that the student will be traveling at their own risk and required to sign the "Air Travel Informed Consent" form.

Air Travel Informed Consent Form

This form should be completed by any student prior to undertaking California State University-affiliated air travel.

Authorization to Operate Privately Owned Vehicle - Student

To be completed when a student will operate a private vehicle on a university sponsored trip/activity.

Authorization to Use Privately Owned Vehicle on State Business (STD 261)

Driver Verification Form. This certification verifies the employee's private vehicle has the minimum amounts of liability insurance coverage, is in safe mechanical condition, and is adequate for use in accordance with the State Administrative Manual (SAM) section 0753. This form advises the State employee that adequate vehicle insurance coverage must be provided by the employee's personal insurance and that personal vehicle insurance is primary coverage in case of vehicle accident.

The supervisor authorized to approve travel shall retain the STD 261 completed authorization form in the employee's personnel file. The authorization form is valid for a period not to exceed one year. Once the STD form 261 is completed, it may be initialed and dated annually by the employee to certify adequate personal auto insurance is current and that the private vehicle is safe for state business use.

Accident Report Forms (Non-auto, Non-employee):

Accident Report (Other than motor vehicle)

Whenever a California State University, Northridge employee observes or has knowledge of a non-vehicular accident/injury to a student, vendor or other campus visitor, the employee should complete an "Accident Report". The prompt (within 48 hours) submission of the report will help establish the circumstances of the accident/injury and may prevent or contain any lawsuit that would follow.

The Risk Management Department requests that the information be as detailed as possible, especially if there are serious injuries. Photos and diagrams can be submitted as necessary. The Accident Report should also be submitted when University or personal property is damaged. Note, this report supplements, but does not replace, any Campus Police report that may be developed.

This report is not intended to be completed and submitted for "employee accidents" or for "motor vehicle accidents" because other forms and procedures apply to them.

Employee Accident & Injury Reports (Workers' Compensation):

Medical Treatment Referral Form

This form, previously called a "yellow card", is completed by the supervisor and used to introduce the injured employee to the medical facility and to give the treating medical facility contact information. It also instructs the medical facility to call the Workers' Compensation Coordinator if there will be some restrictions that may affect the injured employee's ability to return to full duty.

State of California "Employee's Claim for Workers' Compensation Benefits"

This form, DWC Form 1, must be given to the injured employee within 24 hours of the employer's knowledge of the injury/illness, according to state law. The form spells out the benefits an injured employee may be entitled to receive. To meet the time requirement, it may be necessary to mail the form to the injured employee. It is up to the injured employee to complete the form and return it to management, if medical treatment is necessary. Otherwise, it does not have to be returned.

Supervisor's Accident Investigation Report for Employee Injury

The supervisor completes this form [Form 620 (Rev 2-07)] for every reported employee incident or injury/illness occurring on-the job. It should be completed through a one-on-one discussion of the circumstances that caused the accident so that workplace conditions or work practices that contributed to the accident can be corrected. For instructions on what to do for an employee injury see "What to do after a work injury occurs" for supervisors.

Supervisor Accident Investigation Report Guidelines

These guidelines are designed to help the supervisor complete the "Supervisor's Accident Investigation Report" required for any employee accident.

Personal Physician Designation Form

If an employee pre-designates a treating physician, that physician has to have seen that employee within the last year and maintain some of the employee's medical records. This designated physician agrees to accept fees for services that are regulated by the Labor Code. The completed Personal Physician's Designation Form is maintained at the Office of Human Resource Services (UN 180).

State Vehicle & Driver Forms:

STD 261 - Authorization to use Privately Owned Vehicle on State business - Employee

This certification verifies the employee's private vehicle has the minimum amounts of liability insurance coverage, is in safe mechanical condition, and is adequate for use in accordance with the State Administrative Manual (SAM) section 0753. This form advises the State employee that adequate vehicle insurance coverage must be provided by the employee's personal insurance and that personal vehicle insurance is primary coverage in case of vehicle accident.

STD 262 - Travel Expense Claim Form

To submit auto expenses associated with CSUN business travel.

STD 269 - Accident Information Card Form

When the driver of a University or State-owned vehicle is involved in an accident, he/she must record all pertinent information on the Accident Information Card form STD 269 before leaving the scene of the accident. Blank STD 269 cards should be readily available in the glove compartment of each State (rental, owned, leased, or private) vehicle. When another vehicle is involved in an accident with a State vehicle, the appropriate portion of the STD form 269 is completed, detached, and given to the driver of the other vehicle. The State Office of Risk and Insurance Management (ORIM) is the University's third-party auto insurance provider.

STD 270 - Vehicle Accident Report Form

All motor vehicle accidents involving a State-owned vehicle or any vehicle being used on State business must be reported on the Vehicle Accident Report (STD 270) form within 48 hours to the State Office of Risk and Insurance Management (ORIM). If the accident results in bodily injury or significant property damage, the accident must be first reported by telephone and/or fax copy of the STD 270 to the ORIM fax number at (916) 376-5277.

STD 273 - Monthly Travel Log

Any operator of a University vehicle, not permanently assigned to an individual, must complete this monthly travel log and submit to the California Department of General Services if the vehicle is leased from the DGS, or to the department if that department owns or operates the vehicle.

STD 274 - State Driver Accident Review Form

The supervisor of each driver involved in an accident must prepare a State Driver Accident Review form STD 274 to investigate the accident promptly and thoroughly. The supervisor must initiate any verbal or written corrective action; record the action, and forward copies of the completed form to the appropriate campus administration (the CSUN Office of Safety and Risk Management). The purpose of this report is to determine whether the accident was avoidable and to aid in the prevention of future accidents. This State Driver Accident Review (STD 274) must be submitted with the Vehicle Accident Report (STD 270) filed with the State Office of Risk and Insurance Management (ORIM) as well as with your Campus Risk Manager.

Student Authorization - Authorization to Operate Privately Owned Vehicle - Student

To be completed when a student will operate a private vehicle on a university sponsored trip/activity.

Acknowledgement of University Vehicle Policy - Acknowledgement & Verification for University and Private Vehicles

Completed by employee or volunteer verifying their understanding of the University's policies regarding vehicular use.

Powered Cart Training Certification - Employee/Supervisor Training Certification

Every powered cart or low-speed vehicle driver must be certified before driving. It must be renewed every four years.

CSUN Vehicle Use Policies - Vehicle Usage Policy

Policy #450-01 issued from the Office of the Vice President for Administration and Finance.

CSU Department of Public Safety Pull Notice Program - Pull Notice Program

CSU program to verify the California driving records of all State employees authorized to drive on State business. The Department of Public Safety under the direction of the Chief of Police administers this program.

CSU Vehicle Manual - Use of University and Private Vehicles Policy Guidelines

The full manual is available from the CSU Chancellor's Office website.

CSUN Motor Vehicle Purchase Form

This form is required when any department wants to purchase a new vehicle or replace an existing vehicle.

CSUN Monthly Vehicle Usage Report

This monthly report must be filed with HR for all University vehicles permanently assigned to an individual.

PPM Weekly Maintenance Checklist

This vehicle safety and operational checklist is completed weekly for all University vehicles.

PPM Vehicle Inventory Report

This report is filed annually between January 1 and March 15 by every department owning or operating a University vehicle.

ORIM's "OK, You've had a motor vehicle accident, so now what happens?"

In case of an auto accident, additional information is available from the Office of Risk and Insurance Management.

Volunteer Forms:

Volunteer Identification Form (PDF)

Those persons who perform work or provide services to the university without financial gain are Volunteers and must complete this Human Resources form.

Volunteer Participation Informed Consent, Release and Hold Harmless Agreement

Those persons who perform work or provide services on an event or activity on a voluntary basis must complete this Human Resources form.

Purchasing & Contract Forms:

Independent Contractor/Guest Lecturer Waiver

To be completed by an independent contractor prior to commencement of work or service, or by a guest lecturer prior to a lecture.

Insurance Quote Forms:

Foreign Travel Insurance

University Risk Management processes foreign travel insurance for all University approved foreign trips as a cost effective and prudent method of providing for financing of the specialized risks related to foreign travel. The FTIP is designed to provide automatic coverage for faculty, students and others while traveling abroad. Although coverage is automatic, information is needed for every trip as soon as the instructor begins preparing for foreign travel. This will ensure that the participants traveling abroad have proper travel assistance; provide whereabouts in the event of emergency; and record underwriting information for premium allocation. Use the quote form to submit the application.

Inland Marine Insurance

Inland marine is special property insurance designed for scheduled equipment such as musical instruments, art work and special expensive equipment on loan or temporarily being used by a department for which the lender or department would want insurance coverage. To get a quote, contact Risk Management (extension 2079) and submit this quote form

Participant's Accident Insurance

This plan provides primary or excess accident medical coverage when participants suffer accidental injury during sponsored and supervised sports programs or other organized youth activities. The plan is sold as blanket coverage, purchased by a group for all its participants. Participant Accident Insurance program covers a broad range of groups and activities, providing the best possible protection for event participants. With a quick-quote capability and competitive pricing the University Risk Management Department can help you fill your accident-medical-coverage needs. Use this quote form to get a Participant's Insurance quote.

Vendor's Insurance

This Vendor/Contractor Insurance Program as developed to meet the needs of the California State University system in assuring that there is insurance in place when entering into a contract with a contractor or vendor. Coverage can be provided for General Liability, General Liability and Professional Liability combined. This will enable the University to contract with qualified bidders who could not previously participate because their level of insurance could not meet the CSU minimum insurance requirements. Use this quote form to get a Vendor's Insurance quote.

Purchasing & Contracts Administration Forms:

Internship Learning Plan

This is the on-line form that the student intern, site supervisor and faculty/course supervisor sign establishing the internship or service learning agreement.

Request to Initiate an Internship Agreement

This is an electronic form for faculty to complete to request Purchasing & Contract Administration to initiate an Internship/Service Learning Agreement.

Student Internship Guidelines

These are the guidelines and limitations agreed to by the student.

Center for Community Service Learning - Community Engagement:

Community Partner/Site Supervisor Evaluation of Student

This is the student evaluation that is completed by the site supervisor.

Community Partner Profile and Student Request

This form is used by the community organization to request a student intern.

Community Service Partner Handbook

This updated Community Engagement Partner Handbook explains the University's community learning practices and procedures. It defines the types of service in which students can participate, describe the essentials of community learning partnership, and provides resources and forms.

Contact Information

This indentifies the student, faculty and community organization involved with the student's internship or community service learning fieldwork.

Designing a Service Learning Experience

This outline is designed to help guide initial discussions between all parties in the service-learning experience, with the goal of developing mutually beneficial campus and community partnerships.

Service Learning Agreement (Sample)

This is a sample contract for the internship agreement between the community organization and CSUN required for each internship.

Service Learning Informed Consent Form

This consent form, signed by the parent or legal guardian, gives permission for the minor student to enter into an internship.

Service Learning Manual

This older version of the Community Partner Guide to Service-Learning and Volunteerism explains the University's community service practices and procedures. It defines the types of service in which students can participate, describes partnership essentials, and provides information and forms.

Career Center (Student Affairs):

A Guide to Internship Success (students)

This is a pamphlet explaining the benefits, techniques and procedures associated with internships.

Creating an Internship Learning Contract

This explains the guidelines and expectations between the student intern and the employer regarding the internship.

Reporting Complaints or Campus Hazards:

Campus Safety Hazard Reporting Form

You can use this form to detail the hazard you observed.

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