BASIC INITIAL HEALTH & SAFETY ASSESSMENT SUBMISSION

ONLINE SUBMISSION IS ONLY FOR INITIAL BASIC HEALTH & SAFETY ASSESSMENTS

Do not submit ANY OTHER DOCUMENT(S). REVIEW & VERIFY ASSESSMENT HAS BEEN COMPLETED CORRECTLY, PRIOR TO SUBMITTING ONLINE. INCOMPLETE OR INCORRECT INITIAL BASIC HEALTH & SAFETY ASSESSMENT WILL BE RETURNED.

For further instructions on how to submit it online, please review instruction sheet

*denotes required field

Applicant Last Name, First Name

Date of Birth

Island of Residency (select one)

Name of Facility/Center

Applicant’s Email

Director/Center Email (required*)

Applicant’s Phone Number

Director/Center Phone Number

*Required: ATTACH INITIAL BASIC HEALTH & SAFETY ASSESSMENT only
Please submit HEALTH & SAFETY ASSESSMENT for only one individual per submission
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IF THE INITIAL BASIC HEALTH & SAFETY ASSESSMENT IS NOT COMPLETED WITH 100% ACCURACY & COMPLETENESS, YOU (PRIMARY CAREGIVER / DIRECTOR) WILL BE NOTIFIED BY EMAIL OR BY TELEPHONE TO REVIEW THE QUESTIONS THAT WERE ANSWERED INCORRECTLY.

THE CONFIMRATION EMAIL THAT YOU RECEIVE WILL BE UPDATED WITH THE DAY PATCH RECEIVED YOUR ASSESSMENT. IF ASSESSMENT IS CORRECT, YOUR TRAINING PERIOD WILL THEN START (I.E., YOU RECEIVED EMAIL CONFIRMATION ON 2/15/2025; THEN YOUR TRAINING PERIOD WOULD BE: 2/15/2025 – 2/14/2026).

DISCLAIMER: IF ANY INITIAL BASIC HEALTH & SAFETY ASSESSMENT SUBMITTED IS ILLEGIBLE OR ALTERED, PATCH WILL CONTACT YOU & REQUEST THAT YOU MAIL THE ORIGINAL INITIAL BASIC HEALTH & SAFETY ASSESSMENT TO BE PROCESSED.

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INITIAL BASIC HEALTH & SAFETY ASSESSMENT SUBMISSION

BASIC INITIAL HEALTH & SAFETY ASSESSMENT SUBMISSION

IF THE INITIAL BASIC HEALTH & SAFETY ASSESSMENT IS NOT COMPLETED WITH 100% ACCURACY & COMPLETENESS, YOU (PRIMARY CAREGIVER / DIRECTOR) WILL BE NOTIFIED BY EMAIL OR BY TELEPHONE TO REVIEW THE QUESTIONS THAT WERE ANSWERED INCORRECTLY.

THE CONFIMRATION EMAIL THAT YOU RECEIVE WILL BE UPDATED WITH THE DAY PATCH RECEIVED YOUR ASSESSMENT. IF ASSESSMENT IS CORRECT, YOUR TRAINING PERIOD WILL THEN START (I.E., YOU RECEIVED EMAIL CONFIRMATION ON 2/15/2025; THEN YOUR TRAINING PERIOD WOULD BE: 2/15/2025 – 2/14/2026).

DISCLAIMER: IF ANY INITIAL BASIC HEALTH & SAFETY ASSESSMENT SUBMITTED IS ILLEGIBLE OR ALTERED, PATCH WILL CONTACT YOU & REQUEST THAT YOU MAIL THE ORIGINAL INITIAL BASIC HEALTH & SAFETY ASSESSMENT TO BE PROCESSED.

*DENOTES REQUIRED FIELD

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