Special Effects Safety Hazard Assessment

Special Effects Safety Hazard Assessment
Show Title*
Do not include season number
Episode*
Prepared By*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Shoot*

MonthDayYear
Date
Scene Number(s)
Location*
Describe the special effects to be performed in detail:*
How many people involved in the effects, including production crew? *
Diagram of effects

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Describe safety measures used to protect participants, public, and equipment.*

Planning & Communication:

Rows	Yes	No	N/A
If licenses or certifications are required, do SPFX personnel have active and verified required licenses or certification cards in their possession?
Has every piece of equipment been carefully inspected, especially after each use?
If changes have been made, are all parties aware of and comfortable with the changes?
Have proper arrangements been made for emergency medical services, and nearest emergency medical facility listed on the call sheet?
Will SPFX personnel be allowed adequate time to inspect area and rehearse, if necessary?
After each run-through, will the effect be set up to run again exactly as originally planned?
Have you planned procedures for human or mechanical error, outside interference, weather changes, or other unexpected situations?
Have stunt coordinators, performers, AD's, Production Safety, Medic, and Fire Safety all been briefed on the activity?
Have complete SDS (not informational sheets) been submitted to Production Safety for approval for all products planned?

If any of the above are answered "No" please explain here:
Are any of the following involved?

Airborne contaminantsSmoke/Fog effectsChildren/MinorsArtificial snowFire/Pyrotechnics (see below)WaterWeaponsOther
Please note informational sheets using language like "trade secret," "proprietary blend," or other non-specific terms will not be approved and cannot be used until a complete list of ingredients is submitted to Production Safety for review. A Globally Harmonized System of Classification and Labeling of Chemicals compliant SDS must be readily available for every product used.
Upload any supporting documentation (SDS, etc.)

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Fire/Pyrotechnics Questions
What size is the fire/explosion and what materials will be used?
Describe the fire safety in place to prevent injury to persons or damage to property.
Fire Permit Issuer and Permit Number:
Will a Fire Safety Officer be on set?

YesFSO not requiredOther
Personal Protective Equipment (PPE) Assessment
Are hazards to the following present?

EyesFaceHeadHands/ArmsFeet/LegsBody (Skin)Body (Whole)Respiratory SystemEars/HearingOther
What presents the hazard?

Fire/ExplosionsWeapons/AmmunitionChemicals/dust/particulatesConfined spacesExcessive noiseUneven/Unpredictable terrainWater workOther
What exposures are present?

BurnsSlips/Trips/FallsImpact injuriesForce injuriesChemical/Irritant exposureScrapes/Bruises/Cuts/PinchesSensory LossOther
Can the effect be choreographed or directed to eliminate hazard(s)?

YesNoN/AOther
Can hazard(s) be eliminated without the use of Personal Protective Equipment (PPE)?

YesNoN/AOther
What PPE will be used to reduce or eliminate hazards?

Safety Glasses/GogglesFace Mask/ShieldProtective Helmet/Bump Cap/Soft CapFall Protection/Personal Rigging SystemsProtective Clothing/Gloves/ShoesRespiratorEar plugs/Earmuffs/SoundproofingBody Pads/Body Armor/Stunt PadsNo PPE can be used (explain in additional comments)Other
Additional Comments
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Special Effects Safety Hazard Assessment

Fire/Pyrotechnics Questions

Personal Protective Equipment (PPE) Assessment