Safety Partner Registration Form

✻ = Required

First Name: ✻

Last Name: ✻

Email: ✻

Phone number:

Department: ✻

Name of Department Head:
(Director, Dept. Chair, Unit Head, Laboratory Manager / Director)

Location (Building, Room #):

What type of safety partner would you like to register as?

Building Supervisor for Emergency Conditions (BSEC) Building Emergency Staff (BES)

If registering as a BES or BSEC, which building are you registering for?

Comments:

For assistance with this form or for more information regarding Safety Partner roles, please contact Office of Emergency Management by email or phone (951) 827-5528.