This section establishes the foundational production and scene identification details required for all high-risk action sequences. All fields marked mandatory must be completed before proceeding to subsequent sections.
Production Title
Production Company
Unit Number
Scene Number(s)
Shot Number(s)
Script Page Number(s)
Director Name
Stunt Coordinator Name
1st Assistant Director Name
Safety Officer Name
Production Office Contact Number
Shooting Location Name
Full Location Address
Shooting Date
Planned Call Time
Estimated Wrap Time
Anticipated Weather Conditions
Clear & Dry
Partly Cloudy
Overcast
Light Rain
Heavy Rain
High Winds
Extreme Heat
Extreme Cold
Describe contingency plans for inclement weather
Describe contingency plans for inclement weather
Describe wind speed thresholds and abort criteria
Describe heat stress mitigation protocols
Describe cold exposure mitigation protocols
Have local authorities been notified?
Provide notification reference numbers and department details
Justify why authority notification is not required
Production Insurance Policy Number
Insurance Policy Expiry Date
Last Safety Meeting Date & Time
Upload Location Permit & Authorization Documents
Provide exhaustive technical details of the planned action sequence. This section requires precise information for risk calculation and safety protocol development. Incomplete specifications will halt approval.
Stunt Category (Select all that apply)
Vehicle Stunt
Fight Sequence
High Fall
Wire Work & Aerial
Fire & Burns
Explosive Pyrotechnics
Weapons Discharge
Underwater Sequence
Horse & Animal Action
Special Rigging
Other
Vehicle Stunt Details: Describe vehicles, speeds, maneuvers, surfaces
Fight Sequence Details: Describe choreography complexity, weapons, impact levels
High Fall Details: Specify fall height, landing surface, airbag/pad specifications
Wire Work Details: Describe rigging points, harness types, deceleration systems
Fire & Burns Details: Specify burn duration, fuel type, protective gel systems
Explosive Details: Describe charge types, blast direction, fragmentation control
Weapons Details: Specify blank ammunition type, barrel direction, safety distances
Underwater Details: Specify depth, duration, breathing apparatus, safety divers
Animal Action Details: Describe species, training level, handler credentials
Special Rigging Details: Specify load capacities, anchor points, backup systems
Other Stunt Details: Provide comprehensive description
Complete Action Sequence Description
Upload Storyboards & Technical Schematics
Overall Risk Level Assessment
Low Risk (Controlled environment, trained performers, minimal variables)
Medium Risk (Moderate complexity, some variables, established safety protocols)
High Risk (Complex choreography, significant height/speed, multiple performers)
Extreme Risk (Life-threatening potential, unprecedented complexity, severe environmental factors)
Justify High-Risk classification and detail additional oversight measures
Justify Extreme-Risk classification and detail why this risk level is unavoidable for creative vision
Equipment Inventory & Safety Certification
Equipment Item | Quantity | Specification/Model | Safety Certified | Last Inspection Date | Condition Rating (1-5) | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | Airbag Landing System | 2 | 12' x 12' Pro-Stunt Mark IV | Yes | 1/15/2024 | ||
2 | Wire Harness | 4 | Full Body Fall Arrest Pro | Yes | 2/1/2024 | ||
3 | Fire Proximity Suit | 3 | Nomex 3-Layer System | Yes | 1/20/2024 | ||
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Are pyrotechnics or explosive materials involved?
Total Net Explosive Quantity (NEQ) in kilograms
Proceed to non-pyro safety equipment section.
Pyrotechnic Type (if applicable)
Bullet Hits & Squibs
Fireballs & Petrol Bombs
Smoke & Flash Effects
Spark & Sparkle Additives
High Explosive Charges
Other
High Explosive Justification: Explain why lower-yield alternatives are insufficient
Describe Other Pyrotechnic Type
Minimum Safety Distance from Charge (meters)
Blast Radius (meters)
Fallout Zone Clearance Distance (meters)
Licensed Pyrotechnician Name
Pyrotechnician License Number
Pyrotechnician License Expiry Date
Pyrotechnic Storage Location On-Set
Transportation & Handling Protocol
Special Effects Supervisor Name
Is specialized rigging equipment required?
Rigging Details: Anchor points, load calculations, backup systems, certified rigger name
Safety Perimeter Distance from Action (meters)
Will cameras be positioned within the safety perimeter?
Camera Protection Details: Specify barricades, blast shields, remote operation, operator protective equipment
Has a full technical rehearsal been completed?
Rehearsal Date & Time
Scheduled Rehearsal Date & Time
Are safety bulletins posted at all access points?
CRITICAL: Safety bulletins must be posted before any stunt work begins. Approval cannot proceed without this requirement met.
Upload Rigging Certificates & Load Test Reports
This section documents performer credentials, medical fitness, and safety briefing compliance. All performers must be fully qualified and briefed before participating in any high-risk sequence.
Total Number of Performers Participating
Performer Details & Qualifications Log
Full Name | Role/Position | Performer ID Number | Contact Phone | Emergency Contact | Medical Clearance Current | Medical Clearance Expiry | Years Relevant Experience | Certifying Body | ||
|---|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | I | ||
1 | Alex Rodriguez | Lead Stunt Double | SPD-8847 | +1-555-0199 | Maria Rodriguez +1-555-0200 | Yes | 6/30/2025 | 12 | International Stunt Association | |
2 | Casey Lee | Utility Stunt Performer | SPD-9201 | +1-555-0188 | David Lee +1-555-0189 | Yes | 8/15/2025 | 8 | International Stunt Association | |
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Primary Stunt Performer Name
Upload Performer Certification Documents
Upload Medical Fitness Certificates for All Performers
Upload Performer Insurance Certificates
Has a mandatory safety briefing been conducted for all participants?
Briefing Date & Time
Explain why briefing has not occurred and provide immediate action plan
Briefing Location
Briefing Conducted By
Safety Briefing Attendance & Acknowledgment
Performer Name | Attended Briefing | Digital Signature | Acknowledgment Time | ||
|---|---|---|---|---|---|
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Have all performers signed the hazard acknowledgment form?
CRITICAL: All performers must acknowledge hazards before commencement. Approval denied until completed.
Special Medical Conditions or Physical Restrictions for Any Performer
Will any performers require medication on-set during the sequence?
List medications, dosage times, and storage requirements
Does any performer have a history of serious injury from similar stunts?
Describe injury history and mitigation measures
Witness Names & Roles (not participating in stunt)
Observer Names (crew members watching but not directly involved)
This section verifies that all emergency response protocols are established, personnel are in place, and evacuation procedures are clearly defined. This is non-negotiable for high-risk operations.
Have local emergency services been formally notified?
Provide notification date, reference number, department name, and contact officer
Provide justification and alternative emergency response plan
Is a qualified medic present on-set during the sequence?
Medic Name
Explain medic absence and alternative medical coverage plan
Medic License/Registration Number
Medic License Expiry Date
Medic Direct Contact Number
Is an ambulance on standby at the location?
Ambulance Type
Basic Life Support (BLS)
Advanced Life Support (ALS)
Mobile Intensive Care Unit (MICU)
Provide nearest hospital details and emergency transport plan
Ambulance Location on Set
Ambulance Driver Contact
Nearest Hospital Name
Hospital Full Address
Estimated Travel Time to Hospital (minutes)
Has the fire department been notified (required for pyrotechnics)?
Fire Department Notification Reference
Is a dedicated fire watch team assigned?
Fire Watch Personnel Names, Positions, and Equipment Assignments
Fire Suppression Equipment Inventory
Equipment Type | Quantity | Location on Set | Last Inspection | Condition (1-5) | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | CO2 Extinguisher | 4 | North, South, East, West Perimeter | 2/10/2024 | ||
2 | Fire Blanket | 6 | Medic Station, Near Performers | 2/8/2024 | ||
3 | Water Pump Truck | 1 | Behind Video Village | 2/5/2024 | ||
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Available Extinguishing Agents (Select all applicable)
Water
CO2
Foam
Dry Chemical Powder
Wet Chemical
Sand/Dirt
Fire Blankets
Are clearly marked evacuation routes established?
CRITICAL: Evacuation routes must be established and communicated to all personnel. Cannot proceed without this.
Secondary Assembly Point Location (if primary compromised)
Has the emergency communication system been tested?
Communication Check Time
Immediate action plan to test communication system
Is an emergency shutdown procedure documented and communicated?
Document shutdown procedure immediately. This is mandatory.
First Aid Station Locations
Upload Emergency Contact List & Call Sheet
Is a roll-call system established for emergency accountability?
Final authorization section. All previous sections must be complete and verified. This approval signifies that all reasonable safety measures have been implemented and residual risks have been accepted by production leadership.
Risk Assessment Summary & Residual Risk Statement
Final Safety Verification Checklist
Not Verified | Partially Verified | Fully Verified | |
|---|---|---|---|
All performers medically cleared | |||
Safety briefings completed | |||
Equipment inspected and certified | |||
Emergency services notified | |||
Fire suppression ready | |||
Evacuation routes clear | |||
Communication systems tested | |||
Weather conditions acceptable | |||
Insurance coverage verified | |||
Permits and authorizations obtained |
Have all identified hazards been mitigated to the lowest reasonably practicable level?
Detail remaining hazards and justification for acceptance
Do you approve this stunt sequence to proceed?
Approval granted pending final on-set safety verification.
Specify required changes or additional information needed before approval can be granted
Stunt Coordinator Full Name
Stunt Coordinator License/Registration Number
Stunt Coordinator Digital Signature
Stunt Coordinator Approval Timestamp
Executive Producer Full Name
Executive Producer Digital Signature
Executive Producer Approval Timestamp
Is this approval conditional upon any additional requirements?
List all conditions and compliance verification method
Final Authorization Code (to be entered on-set before commencement)
Form Completed By
Form Completion Time
Additional Notes & Special Considerations
To configure an element, select it on the form.