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

Production Title

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?

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

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?

Will this activity involve any live animals?

Does this activity require road closures or public space restrictions?

Current Safety Certifications (select all that apply):

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

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

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?

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

Are you currently taking any prescription medications?

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

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

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

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?

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

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

Will you be operating or working near specialized stunt vehicles?

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

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?

Has a dry-run/rehearsal been completed satisfactorily?

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?

Is this a day or night shoot?

Will artificial lighting or atmospheric effects impact visibility?

Approval Signatures

Has all required safety documentation been filed with production office?

Additional Notes or Special Considerations: