Fillable Effective February 1, 2022 SAFE SRC PLAN FORM (Ryerson Polytechnic University)

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Effective February 1, 2022 SAFE SRC PLAN FORM (Ryerson Polytechnic University)

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Effective February 1, 2022
SAFE SRC PLAN FORM FOR RETURN TO ON-CAMPUS SRC ACTIVITY
New Safe SRC Plan submissions, please fill out Sections 1 and 2 below.
Updates/revisions to existing approved Safe SRC Plans, fill out Section 1 only.
• Please submit a distinct Safe SRC Plan for each unique room, grouping of rooms, or space/
equipment
within a larger room that has distinct access membership in terms of faculty
members.
• Updates/revisions refer to any changes in SRC activities, such as the addition of individuals
accessing the SRC space, etc.
• For your application to be considered you need to complete and submit this form to your
Department Chair or School Director (or delegate).
• You will be notified of any questions or concerns during the approval process and will have
opportunities to revise your plan accordingly.
• You will receive notification if and when your request has been approved at all three levels
(Chair/Director, Dean, the VPRI).
Indicate one of the following (required)
New Safe SRC Plan
Update/Revision to Existing Safe SRC Plan
SRC Space (Building Code and Room Number):
Faculty Member(s) Responsible
Name(s): Signature(s):
Primary Faculty Contact Information
Email: Mobile Phone:
Department/School:
Faculty:
SECTION 1
List All Individuals Requesting Access to Identified SRC Space
Name Student/One Card
Number
Email Type (Student Level and
Year; PDF; Staff)
I hereby acknowledge by checking this box that the individuals listed above have
confirmed their willingness to participate in the proposed on-campus SRC
activities and that they are in adherence with Ryerson University’s current
COVID-19 vaccination protocols.
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SECTION 2
Description of SRC Space
High-level Description of SRC Space:
Safe SRC Plan
A. Describe the Proposed SRC Activities
B. Briefly describe how you will keep track of SRC personnel working in your SRC Space(s),
including the use of a tracking sheet and/or calendar.
C. Describe how public health directives will be followed in your Safe SRC Plan (e.g., the provision of
appropriate PPE (non-medical masks, medical masks, face shields) based upon the anticipated
activities and ability to maintain physical distancing.
Confirmation and Approvals
I verify that the contents of this Safe SRC Plan are complete and accurate, and I also agree to abide
by this Plan, and all Ryerson University and public health directives.
Signature Date
Department/School, Faculty, and VPRI Approvals
Department/School Approval:
Signature Date
Comments:
Faculty Approval:
Signature Date
Comments:
VPRI Approval:
Signature Date
Comments:
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Effective February 1, 2022 SAFE SRC PLAN FORM (Ryerson Polytechnic University)

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Completed 28 February 2022

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