Use this handy form to record your site safety chats. This is a good way to help meet the requirements of the Injury and Illness Prevention Program recordkeeping requirements. Please find attached a request form for a Certificate of Coverage. Please fill out the form and send to the following: Cassandra Thompson-Jervis Fax: (909) 433-4785 Email: cassandra_thompson-jervis@sbcss.k12.ca.us. The certificate will be processed, the original mailed to the Certificate Holder and a copy will be sent to the requester. The Reimbursement Application is to be used by member districts who are applying for Safety Credit reimbursemements. The Loss Damage Report form is used to report property loss or damage to property at a member district. In the event of a district vehicle accident, please use the attached form for reporting the accident. The Board of Directors may use the attached form in seeking reimbursement for expenses incurred while attending a conference or meeting.

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