Request for Dive Safety Records

Boston University Scientific Divers may request any of the following record transfers from BU’s Dive Safety Officer:

Active Status Divers working on joint dive plans with another AAUS institution may require a Letter of Reciprocity
Divers transferring to another institution may request a Verification of Training and/or Transfer of Records

To request any of these transfers, please fill out the form below.

Diver Information
Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State ZIP Code
Date of Birth
MM slash DD slash YYYY
Recipient
I request and authorize Boston University to release information to or furnish copies of my records to the recipient indicated below.
Authorized Recipient
First Last
Name of Organization
Phone
Fax
Nature of Request
By checking any of the boxes below, I authorize the disclosure of the information indicated.
I request that BU's Dive Safety Officer provide the following to the institution listed above:*
- Letter of Reciprocity
- Verification of Training
- Transfer of Records
Project/Dive Information
Please provide details about the dive requiring a Letter of Reciprocity
Project/Plan Name
Project/Plan Name
Project PIPrincipal Investigator View Boston University's policy on...

BU's Dive Safety Officer may verify with the PI whether the diver is acting in an official capacity on behalf of Boston University.
Period of Activity
Brief Description of Activities
Other Divers
First Name Last Name
Means of Transfer
I authorize the exchange of this information by:
- Fax
- Email
Authorization
I hereby knowingly and voluntarily authorize Boston University to disclose/release my records and information in the manner I have described above.*
- I agree
Comments
Any special instructions, or anything else we should know?

Diver Information

First Name	Last Name