External companies with similar activity to the UB (1/4) – Oficina de Seguretat, Salut i Medi Ambient

Remember to complete the entire procedure, which consists of 4 steps .

For this first step , Declaration of the company’s responsibility for compliance in the field of occupational risk prevention, you must fill in the following form.

NOTE: This form is valid for 2 years as long as there are no substantial changes to be notified.

Form

Fields marked with an asterisk (*) are mandatory.

Details of the person(s) who will be carrying out activities at the UB

Specify for each worker, name, surname and email address. You have two options: attach a file with the list of the staff or specify it in the box below:

File with the list of working personnel (Maximum size: 2MB - Accepted extensions: .pdf, .txt, .docx, .xlsx)

Working staff (One person per line)

Details of the activity to be carried out at the UB

Faculty/Center*

UB department/unit/service in which the activity is to be carried out*

Contact person at the UB*

E-mail address of contact person*

Description of the research project or activity*

Planned duration/permanence at the UB*

Details of the institution/organisation/company of origin relating to occupational risk prevention and of the person who will carry out the activities at the UB

Institution of origin*

The institution/organisation/company has the following preventive modality:

Prevention Service (PS)

Own prevention serviceYesNo

Specialities of the own prevention serviceSafetyIndustrial HygieneErgonomics and PsychosociologyHealth Surveillance

Joint prevention serviceYesNo

External prevention serviceYesNo

Others

Details of the external prevention service

Company name/No. of accreditation SP

Address

Telephone/E-mail

Specialities taken onSafetyIndustrial HygieneErgonomics and PsychosociologyHealth Surveillance

I want to include another prevention serviceYesNo

Company name/No. of accreditation SP

Address

Telephone/E-mail

Specialities taken onSafetyIndustrial HygieneErgonomics and PsychosociologyHealth Surveillance

Details of the person designated as interlocutor with the UB

Name and surname*

Position*

E-mail*

It has arranged coverage for accidents at work and occupational illnesses with

Company name/code MATEPSS

Address

Telephone/E-mail

Signature of the interlocutor*
(Draw your signature at the requadre)

Right to information regarding the processing of personal data
(1) The responsible for the processing of your data is the General Secretariat of the University of Barcelona. (2) The purpose of the processing is to manage the prevention of occupational hazards. (3) You have the right to access your data, rectify them, delete them, oppose their processing, request their portability and the limitation of the processing, in certain circumstances. (4) You can consult detailed information on the aforementioned processing

I declare that I have read the information right

I declare that I undertake to provide the information on the UB's personal data processing set out in this form to the UB contact person

(The form may take a few seconds to confirm submission. Please do not resend it or reload the page)

Step 2