Stunt Safety Hazard Assessment
Show Title
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Do not include season number
Episode
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Prepared By
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Shoot
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/
Month
/
Day
Year
Date
Scene Number(s)
Location
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Describe the stunt to be performed in detail:
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How many people involved in the stunt scene, including production crew?
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Diagram of stunt
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Upload photo or drawing
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Describe safety measures used to protect participants, public, and equipment.
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Planning & Communication:
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Yes
No
N/A
Do all stunt personnel have required licenses or certification cards in their possession (SCUBA, motorcycle, etc.) and have they been verified?
Has every piece of stunt 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 stunt personnel be allowed adequate time to inspect area and rehearse?
After each run-through, will the stunt been set up to run again exactly as originally planned?
Have you planned procedures for human or mechanical error, outside interference, weather changes, or anything unexpected?
Have stunt coordinators, performers, AD's, Production Safety, Medic, and Fire Safety all been briefed on the activity?
If any of the above are answered "No" please explain here:
Are any of the following involved?
Animals
Chemicals
Children/Minors
Helicopters/Fixed Wing Aircraft
High Falls/Wire work
Precision Driving (see below)
Fire/Pyrotechnics (see below)
Water
Weapons
Other
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?
Yes
FSO not required
Other
Precision Driving Questions
Maximum driving speed:
Driving Surface
Paved, dirt, etc.
Will any of the wheels leave the ground?
Yes
No
Will driver's vision be impaired at any time?
Yes
No
Describe safety measures used to protect employees, the public, and equipment:
Name of record of driver(s)
Personal Protective Equipment (PPE) Assessment
Are hazards to the following present?
Eyes
Face
Head
Hands/Arms
Feet/Legs
Body (Skin)
Body (Whole)
Respiratory System
Ears/Hearing
Other
What presents the hazard?
Fire/Explosions
Stage Combat/Squibs
Heavy equipment
Vehicles/Aircraft
Heights/Wire work
Weapons
Chemicals/dust/particulates
Extreme weather/temperatures
Confined spaces
Excessive noise
Uneven/Unpredictable terrain
Water work
Other
What exposures are present?
Burns
Slips/Trips/Falls
Impact injuries
Force injuries
Chemical/Irritant exposure
Scrapes/Bruises/Cuts/Pinches
Sensory Loss
Other
Can stunt be choreographed or directed to eliminate hazard(s)?
Yes
No
N/A
Other
Can hazard(s) be eliminated without the use of Personal Protective Equipment (PPE)?
Yes
No
N/A
Other
What PPE will be used to reduce or eliminate hazards?
Safety Glasses/Goggles
Face Mask/Shield
Protective Helmet/Bump Cap/Soft Cap
Fall Protection/Personal Rigging Systems
Protective Clothing/Gloves/Shoes
Respirator
Ear plugs/Earmuffs/Soundproofing
Body Pads/Body Armor/Stunt Pads
No PPE can be used (explain in additional comments)
Other
Additional Comments
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