Daily Film Set, Stunt & Special Effects (SFX) Clearance Form

Production Title

Shoot Date

Call Time

Primary Shoot Location

Scene Number(s) & Description

Production Type

Unit Production Manager (UPM) Name

Safety Coordinator Name

Full Name

Date of Birth

Primary Role/Department

Specific Position for Today's Shoot

Union/Guild Affiliation (if applicable)

Years of Professional Experience in This Role

Have you previously worked on this production?

Specify previous dates and scenes worked:

Are you acting as a Stunt Coordinator or SFX Supervisor today?

List all personnel under your direct supervision for today's stunt/SFX activities:

Select all applicable activity categories for today's work (check all that apply):

Detailed Description of Planned Stunt/SFX Activities

Estimated Risk Level of Activities

Will any minors (under 18) be present or participating in these activities?

Describe safety measures and guardian presence protocols:

Will this activity involve any live animals?

Specify animal type, handler credentials, and safety protocols:

Does this activity require road closures or public space restrictions?

Describe location control measures and public safety notifications:

Current Safety Certifications (select all that apply):

Is your Stunt/Safety certification current and valid for today's date?

When does your certification expire or when did it expire?

Have you completed a safety briefing specific to today's activities?

Safety Briefing Conducted By:

Upload Current Safety Certification Document(s)

Have you reviewed the storyboard and pre-visualization for this sequence?

Have you participated in a walk-through rehearsal of this stunt/SFX sequence?

Explain why no walk-through was conducted and what alternative preparation occurred:

Do you have any known medical conditions that could affect your ability to safely perform today's activities?

Describe condition, treatment, and any necessary accommodations:

Are you currently taking any prescription medications?

List medications and confirm they won't impair performance:

Have you experienced any injury or illness in the past 30 days?

Describe injury/illness, treatment received, and current status:

Are you experiencing any pain, discomfort, or physical limitation today?

Specify location and severity (1-10 scale) of discomfort:

Do you have any allergies (medications, materials, environmental) relevant to today's work?

List allergens and emergency response plan:

Is your tetanus vaccination current (within 10 years)?

Upload Current Medical Clearance Certificate (if required by risk level)

I confirm that I am physically and mentally fit to perform the activities described in this clearance form today.

Will you be handling any firearms or weapons today?

Specify weapon type (prop, blank-firing, replica), safety officer present, and handling protocols:

Will you be working with pyrotechnics, explosives, or incendiary devices?

Specify material type, quantity, licensed pyrotechnician present, and clearance distances:

Will you be working at heights above 6 feet (2 meters)?

Specify maximum height, fall protection equipment, and certified riggers:

Will you be operating or working near specialized stunt vehicles?

Vehicle types (select all):

Will you be using any personal protective equipment (PPE) beyond standard set PPE?

Specialized PPE being used (select all):

Specialized Equipment Checklist

Rate the implementation status of the following safety control measures (1 = Not Implemented, 2 = Partially Planned, 3 = Planned but Not Verified, 4 = Implemented, 5 = Fully Implemented & Verified):

Are there any last-minute changes to the planned stunt/SFX sequence?

Describe changes and confirm they have been reviewed by Safety Coordinator and Stunt Coordinator:

Has a dry-run/rehearsal been completed satisfactorily?

Identify concerns that must be resolved before filming:

Identify any additional hazards not covered in standard assessment:

Overall confidence in safety preparedness for today's activities:

Do you have active professional liability insurance covering stunt/SFX work?

Have you reviewed and understood the production's liability waiver and risk acknowledgment documents?

I acknowledge that I am voluntarily participating in hazardous activities with inherent risks including, but not limited to, physical injury, temporary or permanent disability, or other harm.

I confirm that I have disclosed all relevant medical conditions, injuries, or limitations that could affect my safety or the safety of others.

I understand that I have the right to refuse to perform any activity I deem unsafe without fear of retaliation, and that I must immediately report safety concerns to the Stunt Coordinator or Safety Coordinator.

I agree to follow all safety protocols, directions from authorized safety personnel, and to remain within designated safe zones when not actively performing.

Emergency Contact Name

Emergency Contact Phone Number

Relevant Medical Information for Emergency Responders

Preferred Hospital/Medical Facility (if any)

Do you have valid ambulance/medical evacuation coverage for this location?

Radio/Communication Channel Assigned

Current Weather Conditions

Are weather conditions within acceptable safety parameters for all planned activities?

Specify weather concerns and contingency plans:

Is this a day or night shoot?

Will artificial lighting or atmospheric effects impact visibility?

Describe lighting/fog/smoke effects and safety measures for reduced visibility:

Approval Signatures

Has all required safety documentation been filed with production office?

Additional Notes or Special Considerations: