Stunt Safety Checklist Form 07: Stunt Safety Checklist This form should be completed by the Stunt Coordinator prior to any stunt performance. Step 1 of 3 33% Production Name Date of Stunt MM slash DD slash YYYY Completed By First Last PhoneEmail Basic ProceduresThe below are nine (9) basic procedures to follow when completing the stunt. By checking the box, you are acknowledging that you understand and will follow all procedures. Attach a stunt diagram with submission of this form. Notify all personnel involved of your intention to perform a stunt. Conduct a detailed briefing of the stunt: What will happen, who it will happen to, the hazards involved, emergency procedures and the location of emergency medical facilities. Answer any questions or respond to concerns completely. Allow adequate rehearsal time. Have one last briefing and dry run to insure everyone's understanding. If there are any changes, review them from the beginning. Clear the set of unnecessary personnel. Make sure that communications are absolutely clear between everyone involved. Stunt DetailsDescribe the stunt in detail:How many people will be involved in the stunt scene, including production crew?Describe safety measures used to protect participants, public and equipment: Do all stunt personnel have required licenses or certification cards (e.g. SCUBA, motorcycle, etc.) and have they been verified? Yes No N/A Have safety policies been reviewed and personnel notified, warned and rehearsed? Yes No N/A Have you planned for human error, outside interferences, natural acts, mechanical error and anything unexpected? Yes No N/A Have Safety Data Sheets (SDS) been obtained for any hazardous substance to be used? Yes No N/A Has every piece of stunt equipment been carefully inspected, especially after each use? Yes No N/A Do any safety modifications need to be made? Yes No N/A Explain: Have the cast, stunt coordinator, ADs, production safety coordinators, set medic, fire safety officer and security officers been briefed on the specifics of the stunt? Yes No N/A Have stunt personnel been allowed adequate time to inspect the area and rehearse? Yes No N/A After each run through, has the stunt been set up to run again exactly as originally planned? Yes No N/A If changes have been made, are all involved parties aware of and comfortable with the changes? Yes No N/A Are any of the following involved in the stunt? Helicopter Fixed Wing Aircraft Personnel Cables or Other Special Rigging Animals Children Have safety policies been reviewed and personnel notified, warned and rehearsed, and aerial coordinator's FAA motion picture flight safety manual been reviewed? Yes No N/A Have fall protection, rigging and all other applicable safety policies been reviewed and personnel notified, warned and rehearsed? Yes No N/A If animals are involved, have the procedures for proper animal handling been reviewed? Yes No N/A If children are involved, have you obtained teacher approval? Yes No N/A Have proper arrangements been made for emergency medical services? Yes No N/A Has the nearest emergency medical facility been located and listed on the call sheet? Yes No N/A Is a standby ambulance or helicopter needed? Yes No N/A Stunt Diagram Drop files here or Select files Max. file size: 20 MB. Please attach pre-planned stunt diagram and/or any other applicable documents. SignatureDate MM slash DD slash YYYY Δ Online Form – TP Form 07 – Stunt Safety Inspection Checklist Web Form Builder