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
Have local authorities been notified?
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
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)
Equipment Inventory & Safety Certification
Equipment Item | Quantity | Specification/Model | Safety Certified | Last Inspection Date | Condition Rating (1-5) | |
|---|---|---|---|---|---|---|
Airbag Landing System | 2 | 12' x 12' Pro-Stunt Mark IV | Yes | 1/15/2024 | ||
Wire Harness | 4 | Full Body Fall Arrest Pro | Yes | 2/1/2024 | ||
Fire Proximity Suit | 3 | Nomex 3-Layer System | Yes | 1/20/2024 | ||
Are pyrotechnics or explosive materials involved?
Pyrotechnic Type (if applicable)
Bullet Hits & Squibs
Fireballs & Petrol Bombs
Smoke & Flash Effects
Spark & Sparkle Additives
High Explosive Charges
Other
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?
Safety Perimeter Distance from Action (meters)
Will cameras be positioned within the safety perimeter?
Has a full technical rehearsal been completed?
Are safety bulletins posted at all access points?
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 | |
|---|---|---|---|---|---|---|---|---|---|
Alex Rodriguez | Lead Stunt Double | SPD-8847 | +1-555-0199 | Maria Rodriguez +1-555-0200 | Yes | 6/30/2025 | 12 | International Stunt Association | |
Casey Lee | Utility Stunt Performer | SPD-9201 | +1-555-0188 | David Lee +1-555-0189 | Yes | 8/15/2025 | 8 | International Stunt Association | |
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 Location
Briefing Conducted By
Safety Briefing Attendance & Acknowledgment
Performer Name | Attended Briefing | Digital Signature | Acknowledgment Time | |
|---|---|---|---|---|
Have all performers signed the hazard acknowledgment form?
Special Medical Conditions or Physical Restrictions for Any Performer
Will any performers require medication on-set during the sequence?
Does any performer have a history of serious injury from similar stunts?
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?
Is a qualified medic present on-set during the sequence?
Medic License/Registration Number
Medic License Expiry Date
Medic Direct Contact Number
Is an ambulance on standby at the location?
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)?
Is a dedicated fire watch team assigned?
Fire Suppression Equipment Inventory
Equipment Type | Quantity | Location on Set | Last Inspection | Condition (1-5) | |
|---|---|---|---|---|---|
CO2 Extinguisher | 4 | North, South, East, West Perimeter | 2/10/2024 | ||
Fire Blanket | 6 | Medic Station, Near Performers | 2/8/2024 | ||
Water Pump Truck | 1 | Behind Video Village | 2/5/2024 | ||
Available Extinguishing Agents (Select all applicable)
Water
CO2
Foam
Dry Chemical Powder
Wet Chemical
Sand/Dirt
Fire Blankets
Are clearly marked evacuation routes established?
Secondary Assembly Point Location (if primary compromised)
Has the emergency communication system been tested?
Is an emergency shutdown procedure documented and communicated?
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?
Do you approve this stunt sequence to proceed?
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?
Final Authorization Code (to be entered on-set before commencement)
Form Completed By
Form Completion Time
Additional Notes & Special Considerations