Hazardous Activity Request Form

Please check the box for all types of hazardous activities associated with your project: (check all that apply) *

Animals (working around, handling or riding)
Building Construction Site (working in)
Climbing/Rappelling
Cooking
Dancing
Drones
Extreme Temperatures or Weather
Fighting
Firearms
Investigative/Exploratory Journalism
Loud Noise (over 70 decibels)
Rigged or Aerial Jumps/Stunts (including choreographed falls, "flying", skydiving, hang gliding and bungee jumping)
Special Effects - Hazers/Fog
Special Effects - Pyrotechnics/Fire
Sports
Vehicles (including watercraft, aircraft and automobile)
Water Activities (including Diving, Snorkeling, Surfing and Swimming)

Before proceeding, please note the following:

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Payroll Company *

Cast & Crew
CAPS
Media Services
The Team Companies

Segment *

Production / Event Company *

Project / Tour *

Primary Contact Name *

First

Last

Email *

Primary Contact Phone Number *

Secondary Contact Phone Number

Please list each activity's expected dates and locations below:

Activity 1 *

Start Date *

End Date *

Location / Address *

Activity 2 (if applicable)

Start Date

End Date

Location / Address

Activity 3 (if applicable)

Start Date

End Date

Location / Address

Activity 4 (if applicable)

Start Date

End Date

Location / Address

Activity 5 (if applicable)

Start Date

End Date

Location / Address

Activity 6 (if applicable)

Start Date

End Date

Location / Address

Activity 7 (if applicable)

Start Date

End Date

Location / Address

Activity 8 (if applicable)

Start Date

End Date

Location / Address

Activity 9 (if applicable)

Start Date

End Date

Location / Address

Activity 10 (if applicable)

Start Date

End Date

Location / Address

Activity Details: Animals

Animals: 1. What type of animals are likely to be encountered and how will they be involved in the project? *

Animals: 2. Please list the Animal Handler/Wrangler's [A] # of years of experience with these animals and [B] link to their website or resume *

Animals: 3. Is the animal handler/wrangler on our payroll? *

Yes
No

Animals: 4. Will anyone on our payroll be riding animals? *

Yes
No

Animals: 4.a. What animals will they be riding? *

Animals: 4.b. How many years of experience does/will each rider have riding these animals? *

Animals: 4.c. What is the fastest speed (MPH) each rider will be going? *

Animals: 4.d. What safety gear will the riders wear? *

Animals: 5. Is any of the wildlife you may be encountering known to be potentially venomous/poisonous or threatening to humans? *

Yes
No

Animals: 6. Please describe the safety precautions being taken to minimize the chance of animals injuring employees on our payroll? (ex. avoiding the animals, handling methods, distance, barriers, protective gear etc.) *

Animals: 7. Will anyone on our payroll that is allergic to these animals be present? *

Yes
No

Animals: 8. How many employees on our payroll will be riding, handling or near the animals? *

Animals: 9. Will there be a medic present? *

Yes
No

Activity Details: Building Construction Site

Construction: 1. Will there be active construction activities taking place while our employees are on site? *

Yes
No

Construction: 2. Will a representative of the construction company be supplying any safety personnel to escort our employees through the premises? *

Yes
No

Construction: 3. Please describe any precautions being taken to avoid accidental injuries: (avoiding certain structures/machinery, work boots, hard hats, eye protection etc.) *

Construction: 4. Will employees on our payroll be climbing onto any scaffolding, elevated surfaces, non-railed stairs/balconies or unstable structures? *

Yes
No

Construction: 4.a. Please describe the surfaces they will be walking on and what precautions are being taken to prevent accidental falls

Construction: 5. Has the construction company or property owner required your production company to sign any waivers of liability or hold harmless agreements? *

Yes
No

Construction: 6. Will any employees on our payroll be operating any tools or construction machinery? *

Yes
No

Construction: 6.a. Please specify which tools/machines they will be using and for what purpose *

Construction: 6.b. Please describe any safety training they will receive or have received prior to using these tools/machines *

Activity Details: Climbing/Rappelling

Climbing/Rappelling: 1. Will anyone on our payroll participate in climbing/rappelling? *

Yes
No

Climbing/Rappelling: 1.a. Will safety harnesses be worn at all times throughout the activity? *

Yes
No

Climbing/Rappelling: 1.b. What surface type/size will they be landing on and what is the max speed at which they will land? *

Climbing/Rappelling: 1.c. What devices will be used to control the speed of descent/falls, if any? *

Climbing/Rappelling: 2. Will any climbing or rappelling take place on any natural rocks, boulders, mountains, glaciers or inside caves? *

Yes
No

Climbing/Rappelling: 2.a. Will any of our employees be Free-Soloing (no harness and/or no fall protection)? *

Yes
No

Climbing/Rappelling: 2.b. Can you please provide a short summary of each climber's experience including number of years climbing? *

Climbing/Rappelling: 2.d. How many satellite phones will you have in the event of an emergency?* *

Climbing/Rappelling: 2.e. Are Oxygen supplies needed (or recommended) at any specific heights or depths in order to complete this route? *

Yes
No

Climbing/Rappelling: 2.f. Please identify the type of routes being climbed/rappelled *

Pre-existing route with existing anchors
Pre-existing route, but will be establishing new anchors
New route without existing anchors

Climbing/Rappelling: 3. Will you be using the services of any private tour or guide companies? *

Yes
No

Climbing/Rappelling: 3.a. Please provide the tour or guide company's business name and website.* *

Climbing/Rappelling: 4. Can you please provide a brief description of where/at what height the climbing will begin, progress and end? *

Climbing/Rappelling: 5. Can you please describe what safety gear the participants will be wearing (i.e. helmet, elbow/knee pads, gloves etc.)? *

Activity Details: Cooking

Cooking: Will employees on our payroll be doing the cooking? *

Yes
No

Cooking: 1. Will there be any cooking with hot oil or large open flames? *

Yes
No

Cooking: 2. Will employees on our payroll be using knives? *

Yes
No

Cooking: 2.a. Please describe how the knives will be used: *

Chopping food
Juggling/Throwing/Catching

Cooking: 2.b. Please describe what will take place and what precautions will be taken to prevent injuries:

Cooking: 3. Will employees on our payroll be performing any flair bartending? (Juggling/Tossing/Catching bottles) *

Yes
No

Activity Details: Dancing

Dancing: 1. Will there be any unique stunts such as aerial/acrobatic dancing, high tosses, jumping off high platforms, choreographed falls, dancing in water, etc.? *

Yes
No

Dancing: 1.a. Please describe how the stunt will be performed. *

Dancing: 1.b. Please describe any harnessing involved: *

Dancing: 1.c. What height will participants be rappelling from? *

Dancing: 1.d. What surface type/size will they be landing on and what is the max speed at which they will land? *

Dancing: 2. Will there be any pyrotechnics? *

Yes
No

Dancing: 3. Will there be any hazers/fog machines? *

Yes
No

Dancing: 4. Number of employees participating in this activity?

Activity Details: Drones

Drones: 1. Will the drone by flying over people? *

Yes
No

Drones: 1.b. Please list the Drone Pilot's [A] # of years of experience and [B] link to their website or resume

Drones: 2. Will there be a separate spotter looking out for safety hazards? *

Yes
No

Activity Details: Extreme Temperatures or Weather

Extreme Temperatures or Weather: 1. What are the expected temperatures or conditions? *

Extreme Temperatures or Weather: 2. What precautions will be taken or safety gear used to protect against injury or illness? *

Extreme Temperatures or Weather: 3. Where will the extreme temperature or weather exposure take place and how many hours (per day) will employees be exposed to it? *

Activity Details: Fighting

Fighting: Please describe the type of fighting involved *

Fighting: 2. Will any employees on our payroll be hit by any hard, dense or sharp objects? (if soft/safe props are used, you may answer “No”) *

Yes
No

Fighting: 2.a. Please describe the type, material, weight and dimensions of the object being used to hit the employee? *

Fighting: 3. Will there be any simulations of hard falls, landings, trips or slips? *

Yes
No

Fighting: 3.a. From what height will the fall take place? *

Fighting: 3.b. What type of padding or surfaces will be used to safely break the falls? *

Fighting: 4. Number of employees participating in this activity? *

Fighting: 5. How many years of experience do the stunt people have performing these stunts? *

Activity Details: Firearms

Firearms: 1. Will Live Rounds (real bullets) be used? *

Yes
No

Firearms: 1.a. What type of rounds will be used and what precautions will be taken to ensure the safety of employees on our payroll? *

Firearms: 1.b. What type of eye or ear protection will be used by those participating or near the firearm discharge? *

Firearms: 1.c. What type of targets will be used and what precautions will be taken to prevent any injuries from bullet ricocheting? *

Firearms: 2. Will Blank/Flash Rounds (simulation bullets) be used? *

Yes
No

Firearms: 2.a. What type of eye or ear protection will be used by those participating or near the firearm discharge? *

Firearms: 3. Will any employees on our payroll wear squibs? *

Yes
No

Firearms: 3.a. Please describe any protective padding they will wear. *

Firearms: 4. Who is responsible for checking/storing the weapons? *

Firearms: 4.a. Please list the # of years of experience this person has handling firearms and any current certifications held *

Firearms: 5. Have all individuals handling firearms received (or will receive) firearms safety training prior to use? *

Yes
No

Activity Details: Investigative Journalism

Investigative Journalism: 1. What/who is the subject of your investigation/exploration and what is the project intended to reveal/highlight? *

Investigative Journalism: 2. Please describe the interviewer/journalist's experience exploring this particular subject and working under these conditions/circumstances *

Investigative Journalism: 3. Please identify any support staff you will have: *

Investigative Journalism: 3.a. How long have you worked with this party? If this is a new contact, how were they referred to you? *

Investigative Journalism: 3.b. What experience does this party have investigating or working with this content subject?

Investigative Journalism: 4. How will interviews or content be recorded? *

Covertly (Hidden Cam/Mic)
Openly (Exposed Cam/Mic)

Investigative Journalism: 5. Are any of the individuals you are interviewing or working with convicted of, suspected of, or involved in, criminal activities? *

Yes
No

Investigative Journalism: 5.a. Please describe the criminal activities they have been convicted of, suspected of, or are involved in *

Investigative Journalism: 5.b. Are any individuals you are interviewing or working with likely to be armed with firearms? *

Yes
No

Investigative Journalism: 5.c. Will the interviewer/journalist ever be alone with interviewees/persons being recorded without the film crew present? *

Yes
No

Investigative Journalism: 6. Where are interviews or content expected to be recorded? *

Publicly accessible bars, restaurants or retail businesses
Private offices, hotel rooms or homes
Structures, facilities, camps or villages in rural or remote areas

Investigative Journalism: 6.a. How will the interviewer/journalist get to the interview/content location? *

Driving self to coordinates provided by interviewee
Transported by interviewee while blindfolded
Transported by interviewee without blindfold

Investigative Journalism: 6.b. Are these areas currently undergoing any territorial disputes or armed conflict with an adversary of the interviewee/subject of content? *

Yes
No

Investigative Journalism: 6.c. Will the interviewer/journalist be equipped with a GPS tracker at all times? *

Yes
No

Investigative Journalism: 7. Which party is responsible for sourcing interviewees/content subjects? *

Your Production Company
Local Fixer / Local Production Company

Investigative Journalism: 7.a. How are interviewees/content subjects vetted/incentivized to ensure the safety of the journalist/interviewer? *

Investigative Journalism: 7.b. Has the Production or Fixer met the interviewees/content subjects in person before? *

Yes
No

Investigative Journalism: 7.c. How long has the Production or Fixer had a relationship/dialogue with the interviewees/content subjects? *

Investigative Journalism: 7.d. Did the interviewee(s)/content subjects initiate the request for interview(s)/recording? *

Yes
No

Investigative Journalism: 8. When will interviews or explorations take place? *

Day
Night
Both (Day and Night)

Investigative Journalism: 9. Are the interviews, interview locations and/or neighborhoods being worked in all scheduled in advance of arrival or will these change as the investigation/exploration develops? *

Investigative Journalism: 10. Please describe any safety procedures or protocols in place to limit potential exposure to dangerous confrontations or situations during interviews/explorations *

Investigative Journalism: 11. Have you obtained a security assessment of the intended work areas from any internal or third party security consultants?

Yes
No

Investigative Journalism: 12. How many days are estimated to be spent conducting interviews or recording content subjects? *

Investigative Journalism: 13. How many days are estimated to be spent working in dangerous neighborhoods? (copy) *

Activity Details: Loud Noise

Loud Noise: 1. What is the max decibels the sound is expected to reach? *

Loud Noise: 2. What type of ear protection will you use and what is its Noise Reduction Rating (NRR)? *

Activity Details: Rigged or Aerial Jumps/Stunts

Rigged or Aerial Jumps/Stunts: Please provide a brief description of the stunt/sequence of events: *

Rigged or Aerial Jumps/Stunts: 1. Will any employees on our payroll be participating in any of the following? (check all that apply or "None of these apply") *

Rigged or Aerial Jumps/Stunts: 1.a. Are participants going Tandem (with a licensed instructor) or solo? *

Rigged or Aerial Jumps/Stunts: 1.b. If any aircraft companies are contracted with or chartered for this activity, we require that you obtain a copy of their Liability Insurance certificate prior to the date of the activity. The certificate must show the company's Liability coverage limits for Bodily Injury and Property Damage, which can be no less than $1 Million Per Claim / Passenger. *

I acknowledge that I will obtain a copy of the Aircraft company's Liability Insurance certificate showing no less than $1 Million Per Claim / Passenger.

Rigged or Aerial Jumps/Stunts: 1.c. Please provide the name and website of the company facilitating this activity. *

Rigged or Aerial Jumps/Stunts: 1.d. Please describe the precautions taken by the safety coordinator (or tour company) to prevent improper descent or unsafe landings?

Rigged or Aerial Jumps/Stunts: 2. Will any employees on our payroll be performing any stunts, falls or rigged jumps from heights?* *

Yes
No

Rigged or Aerial Jumps/Stunts: 2.a. Will the employee be wearing any of the following throughout the stunt? (check all that apply) *

Safety Harness
Safety Wire
Decelerator
None of the above

Rigged or Aerial Jumps/Stunts: 2.b. From what height (ft) and surface will jump/fall be made? *

Ex. cliff, bridge, elevated platform, scissor lift, scaffold etc.

Rigged or Aerial Jumps/Stunts: 2.c. What is the vertical distance (ft) between the jump off point and the landing point? *

Rigged or Aerial Jumps/Stunts: 2.d. What surface type/size will they be landing on and what is the maximum speed at which they will land? *

Rigged or Aerial Jumps/Stunts: 2.e. Will the landing be on a moving surface and require precise timing? *

Rigged or Aerial Jumps/Stunts: 2.g. What is the horizontal distance (ft) they will be jumping (how far will the landing area/pads be from the initial jump point)? *

Rigged or Aerial Jumps/Stunts: 2.h. Please list the Stunt Rigger's [A] # of years of experience rigging these types of stunts and [B] link to their website or resume

Rigged or Aerial Jumps/Stunts: 2.i. Who will be responsible for all winch pulling and creation of rigging points? *

Rigged or Aerial Jumps/Stunts: 2.j. Are pre-performance inspections on the rigging equipment and training for the performers conducted? *

Yes
No

Rigged or Aerial Jumps/Stunts: 2.k. Are harnesses designed and fitted to account for the weight and height of all performers and/or objects involved in the stunt? *

Yes
No

Rigged or Aerial Jumps/Stunts: 2.m. Are the rigging systems designed with a safety back-up in case the operator fails to support the weight? *

Rigged or Aerial Jumps/Stunts: 3. Are rigging services or equipment being contracted out (not on our payroll)? *

Yes
No

Rigged or Aerial Jumps/Stunts: 3.a. If any rigging services or equipment are contracted, we require that you obtain a copy of their Liability Insurance certificate prior to the date of the activity. The certificate must show the company's Liability coverage limits for Bodily Injury and Property Damage, which can be no less than $1 Million Per Claim. *

I acknowledge that I will obtain a copy of the rigging contractor or guide company's Liability Insurance certificate showing no less than $1 Million Per Claim.

Rigged or Aerial Jumps/Stunts: 4. Will there be a medic or emergency responder onsite? *

Yes
No

Rigged or Aerial Jumps/Stunts: 5. Will the jump/fall start (departure point) and end (landing point) areas be closed off to surrounding foot traffic? *

Activity Details: Special Effect Hazers/Fog

Special Effect Hazers/Fog: 1. Please describe the special effect, devices and substances involved. *

Special Effect Hazers/Fog: 2. Is the haze liquid/substance hazardous to human health or flammable? *

Yes
No

Special Effect Hazers/Fog: 2.a. Please advise what precautions will be taken to prevent injuries/illnesses? *

Activity Details: Special Effect Pyrotechnics

Special Effect Pyrotechnics: 1. Please indicate how employees on our payroll will be involved in this activity: *

Coordinating safety for stunts
Performing stunts
Preparing the stunts
Working around stunts

Special Effect Pyrotechnics: 1.a. How many times have these employees successfully performed or coordinated these types of activities in the past? *

Special Effect Pyrotechnics: 1.b. Please list any relevant certifications or licenses they hold regarding pyrotechnic safety.

Special Effect Pyrotechnics: 1.c. How many employees on our payroll will be [A] performing stunts and [B] coordinating safety for stunts? *

Special Effect Pyrotechnics: 2. Please describe [A] the type of explosives or flammables involved and [B] how they will be used: *

(Ex. Gas bomb, propane cannon, flame bars, spark producing devices, butane poppers etc.)

Special Effect Pyrotechnics: 2.1. Will any employees' body parts be set on fire?

Yes
No

Special Effect Pyrotechnics: 2.1.1. Which body parts and for how many seconds? *

Special Effect Pyrotechnics: 2.2. How many times will this stunt be performed/attempted? *

Special Effect Pyrotechnics: 3. Please describe the Personal Protective Equipment performers will use to avoid being burned: (gel, water, fireproof clothing/gloves/footwear, eye/head/face coverings, etc.) *

Special Effect Pyrotechnics: 4. What is the expected diameter (in feet) of the flames and what direction will they be traveling relative to where our employees will be? *

Special Effect Pyrotechnics: 5. How far away (in feet) from the flames/pyro will employees on our payroll be positioned? *

Special Effect Pyrotechnics: 6. Do any pyrotechnic/explosion sequences involve simulations of hard falls, landings, trips or slips? *

Yes
No

Special Effect Pyrotechnics: 6.a. From what height will the fall take place? *

Special Effect Pyrotechnics: 6.b. What type of padding or surfaces will be used to safely break the falls? *

Special Effect Pyrotechnics: 7. Will there be a medic on site to respond to injuries? *

Yes
No

Activity Details: Sports

Sports: 1. What type of sports activities will be performed by employees on our payroll? *

Sports: 1.a. Will this activity involve any physical contact with other participants? *

Yes
No

Sports: 1.a.1. Please describe the type of physical contact expected between participants: *

Sports: 2. How fast will they be moving? (miles per hour) *

Sports: 3. Will any stunt jumps/tricks be performed or steep surfaces involved? *

Yes
No

Sports: 3.a. Please describe the stunts and how they will be performed *

Sports: 3.b. If this activity is performed on steep surfaces, what is the slope? (degree of angle) *

Sports: 3.c. How high above the ground will they be? *

Sports: 4. What type of safety gear will be used? (helmets and knee/elbow pads, crash pads/floor mats etc.) *

Sports: 5. What type of environment(s) will these sports be performed in? (check all that apply) *

Closed and controlled set
Publicly accessible/open areas

Sports: 6. Where will this take place? *

Sports: 7. Please describe each participating employee's number of years of experience in this sport (as well as performing any of the scheduled stunts): *

Activity Details: Vehicles

Vehicles: 1. What type of vehicles will be involved? (check all that apply)

Vehicles: 1.a. Please describe how the vehicle(s) will be used in the project, maximum speeds expected (MPH) and planned maneuvers: *

Underwater Vehicles: 1.b.1. Will they remain in the sub at all times? *

Underwater Vehicles: 1.b.2. What processes or procedures are in place to prevent and treat decompression sickness? *

Underwater Vehicles: 1.b.3. Is this sub custom-built or is it manufactured by a specific company? If so, which company? *

Underwater Vehicles: 1.b.4. Can you please describe the sub's emergency communication method in case of comms loss? *

Underwater Vehicles: 1.b.5. What procedures are in place to resurface in case of power failure or loss of control of the sub? *

Underwater Vehicles: 1.b.6. Is this sub tethered to a surface boat or is it free-moving? *

Vehicles: 2. How many years of experience do the vehicle operators have operating the type of water/air/land vehicle(s) involved and how many times (estimate) have they performed these types of maneuvers? *

Vehicles: 3. Are all vehicle operators licensed or certified (where applicable by local regulations) for the type/class of vehicle they are operating? *

Vehicles: 4. If any vehicles (that are not owned nor rented by your company) will be operated near or transporting employees on our payroll (such as with private charter vehicles or vendors contracted by your company) for this project, we require you obtain a copy of their Liability Insurance certificate prior to the date of the activity showing the Liability coverage limits for Bodily Injury and Property Damage, which can be no less than $1 Million Per Claim/Passenger for Land or Air Vehicles, $500,000 Per Claim/Passenger for Water Vehicles (unless exempt by local law). Please confirm you will obtain a copy of any necessary insurance certificates. *

I acknowledge that, if the above applies, I will obtain a copy of the Vehicle Owner's Liability Insurance certificate showing no less than $1 Million Per Claim/Passenger for Land or Air Vehicles, $500,000 Per Claim/Passenger for Water Vehicles (unless exempt by local law).
I cannot comply with the above requirement

Vehicles: 4.1. Please explain why you are not able to comply with this requirement:* *

Vehicles: 5. Will any vehicle stunts be performed? *

Yes
No

Vehicles: 6. What type of environment will these vehicles be operated in? (check all that apply)

Closed and controlled set
Publicly accessible/open areas

Vehicles: 7. If any follow vehicles are involved, how far will they be from the primary vehicle? *

Vehicles: 8. What will employees on our payroll be doing in relation to the vehicle? (check all that apply) *

Operating the vehicle
Passengers of/on the vehicle
Working near/around the vehicle (not passengers)

Vehicles: 8.a. For any employees that are Passengers of the vehicle, please list their [A] Full Name and [B] Type of vehicle they will be riding in *

Vehicles: 8.b. For any employees that are Operating the vehicle, please list their [A] Full Name and [B] Type of vehicle they will be operating *

Vehicles: 9. Please describe what safety gear the vehicle(s) or operator(s)/passenger(s) will be quipped with (ex. Vehicle Roll Cage, Vehicle Seat Belts, Plexiglass Windows, Retrofitted Engine/Battery, Life Jackets etc.) *

Activity Details: Water Activities

Water Activities: 1. Please indicate which water activities employees on our payroll will be engaging in: *

Freediving (underwater diving without breathing apparatus)
SCUBA Diving (up to 60 feet deep)
Deep Diving (up to 130 feet deep)
Technical Diving (over 130 feet deep)
Snorkeling
Swimming (including sitting or standing in water)
Surfing

Water Activities: 1.a. Are all divers PADI certified for these depths and experienced swimming in the scheduled depths? *

Water Activities: 1.b. Where will the nearest recompression chamber be stationed for emergencies? *

Water Activities: 1.c. How many feet below the surface will the diving take place?* *

Water Activities: 1.d. Will each diver be accompanied by a PADI certified safety diver? *

Water Activities: 1.e. Please list the full names of each employee on our payroll that is diving: *

Water Activities: 2. Will there be a medic or emergency responder onsite? *

Yes
No

Water Activities: 3. Will any employees on our payroll be required to perform underwater tricks or hold their breath for long periods of time (without the use of a breathing apparatus)? *

Yes
No

Water Activities: 4. Will any watercrafts be used? *

Yes
No

Water Activities: 5. Is any of the wildlife you may be encountering known to be potentially venomous/poisonous or threatening to humans? *

Yes
No

Water Activities: 5.a. What type(s) and species of wildlife are likely to be encountered or involved? *

Water Activities: 5.b. Will the waters be baited in order to attract the wildlife? *

Yes
No

Water Activities 5.b.1. Please describe the type of bait to be used and how it will be deployed. *

Water Activities 5.c. How close (in feet) will participants get to the wildlife? *

Water Activities 5.d. Will anyone on our payroll be conducting any experiments, tagging, touching, or rendering treatment to the wildlife? *

Water Activities: 6. Please describe the safety precautions being taken to minimize the chance of animals injuring cast or crew? (ex. avoiding the animals, handling methods, distance, barriers, defensive/protective gear etc.) *