Author: Mads Frimann Madsen

Declaration - before fieldwork commences / To be filled in by responsible DTU employer/leader/supervisor as well as the station employee/student
Name of responsible leader - as well as university unit:	Name of stationed employee/student:
Name of responsible external supervisor/field leader*:	Name of representative in local working environment organisation:
Place for field work (country):	Period for field work:
Working environment and risks
Where does the work take place (laboratory, forest, inland ice, ...):
What type of work? / Describe in brief the job function
What known risks are associated with the work?
How are these risks prevented? / (Safety equipment, technical and personal protective equipment)
Which emergency response must be followed if an accident occurs?
In case of risky work, the stationed is instructed that working alone is not acceptable unless the DTU leader has assessed that it is ok	[Yes] □
Which local working environment representative can be contacted (in addition to the DTU leader) if the stationed is unsure whether work is being done safely.	[Name]: / [tel.]: / [email]:
Describe how often the DTU leader follows up on the safety and health conditions. (See follow-up form for field work)
Are there thought of any other essential circumstances / (specify which) e.g. Known risk areas, vaccinations, etc. **	[Yes] □ : what:
The guidelines for manager responsibility for the stationed employee under field work are complied with (described at DTU-Inside)	[Yes] □ / [No] □ : What deviations:
The guidelines for stationed responsibilities under field work are complied with (described at DTU-Inside)	[Yes] □ / [No] □ : What deviations:
Where is this declaration maintained?
This declaration is signed by	Date and signature
DTU leader (under responsibility)
Stationed employee/student
Local working environment representative
* If the field leader is not from DTU, the field leader's responsibility goes to the DTU leader or DTU supervisor - The declaration of DTU field leader is also filled in. / ** A consent declaration must be signed if field work involves a trip to a possible risk area - contact HR