2. Production Name:
Production Address:
Start date
Distribution
Who gets a copy of the assessment
Risk Assessment Form - Part A
Outline of risk assessment
Summary of what is proposed in
terms of sequences and set ups.
Team members I experts I
contractors I contributors etc.
List those involved
Locations
Outline locations involved - indicate
any which are hostile environments
4-3 rruroC-" mor
Assessor Date completedName
Signature
Authoriser
(if not Assessor)
Name
Signature
Date authorised
Hazard list - select your hazards from the list below and use these to complete Part B
'Situational hazards TicK: Physical I chemical hazards Ticl5 . Health hazards . - ··,-1
'-Tick, ,'- , - _'",_ - : > ~ .. - .,. ..."._._
Assault by person / Contact with cold liquid / vapour Disease causative agent
Attack by animal Ii Contact with cold surface Infection
Breathing compressed gas Contact with hot liquid / vapour Allergic reaction
Cold environment Contact with hot surface Lack of food / water
Crush by load Electric shock Lack of oxygen
Drowning Explosive blast Physical fatigue
Entanglement in moving machinery Explosive release of stored pressure I Repetitive action
High atmospheric pressure Fire V Static body posture I
Hot environment Hazardous substance Stress / anxiety V
Manual handling Ionizing radiation Venom poisoning
Object falling, moving or flying Laser light
Obstruction / exposed feature Lightning strike J ~!1,,'{J[.Q_PJ1L~~~~~,,:~~~ .....,~ .. _;.;'
i ~ - ..I
. ~.~~
Sharp object / material V Noise J Litter
Shot by firearm Non-ionizing radiation Nuisance noise / vibration
Slippery surface Stroboscopic light Physical damage
Trap in moving machinery Vibration Waste substance released into air
Trip hazard ..; Waste substance released into soil/water
Vehicle impact / collision Man~~eriall organisational hazards
Falls from height Management factors (lack of communication,
co-operation, co-ordination and competence)
Risk matrix - use this to determine risk for
each hazard i.e. 'how bad and how likely' Likelihood of Harm
Likely
Slight e.g. small cut, deep bruise Trivial
Low
Low Low Medium
PossibleVery unlikely UnlikelyRemote
Severity of Harm e.q. <1 in 1000 chance e.g, 1 in 200 chance e.g. 1 in 50 chance e.g. 1 in 10 chance e,g, >1 in 3 chance
Negligible e.g. small bruise Trivial Trivial Trivial Low Low
Moderate e.g. deep cut, torn muscle
Trivial
Severe e. g. fracture, loss of consciousness
Very Severe e.g. death, permanent disability
Low Medium
Trivial
MediumLow
3. · eOCA TION RELEASE
(~~~e~s~r&,~*vmU~'=Ml~~~20023Owner hereby grants to St Pauls Catholic College ("Company") and Mr Robert Cranham ("Producer") and their
respective parents, subsidiaries and affiliates, licensees, successors and assigns, for good and valuable
consideration, receipt of which is hereby acknowledged, permission to enter upon and use the property and the
ont ts .e f IJd O. purtenances thereto located at
---1____"~I--'----1..L...:...--L.>...L_'__"-""""""""'-"",""" __ -=-'-"_'_"'--+-'-'""-L.__,,,_,__ (the "Property") for the purpose of photographing
and recording certain scenes in co ection with a program tentatively titled "AS Media Studies Coursework" ("the
Program") during production thereof, and as necessary during any extension, reshooting or preparation of publicity or
promotion therefor. All physical embodiments of filming, recording and photography on the Property shall hereinafter
be known as the "Materials".
Company and/or Producer may place all necessary facilities and equipment on the Property and agree to remove
same after completion of work and leave the property in as good of condition as when received.
Company and/or Producer will use reasonable care to prevent damage to said Property, and will indemnify the
owner, and all other parties lawfully in possession, of said Property, and hold each of them harmless from any claims
and demands of any person or persons arising out of or based upon personal injuries, death or property damage
suffered by such person or persons resulting directly from any act of negligence on Producer and/or Company's part
in connection with Producer and/or Company's use of the Property.
Owner grants to Producer and/or Company all rights of every kind in and to the Materials, including without limitation
the right to exploit the Materials throughout the world, an unlimited number of times, in perpetuity, in any and all
media, now known or hereafter invented, and in connection with the Program, Company or otherwise and for
advertising and promotional purposes in connection therewith, and all rights, including copyright, in the Materials shall
be and remain vested in Producer and/or Company, and neither Owner, nor any tenant, nor any other party now or
hereafter having an interest in the Property shall have any right of action against Producer and/or Company or any
other party arising out of any use of said Materials, whether or not such use is, or may be claimed to be, defamatory,
untrue or censorable in nature.
The undersigned acknowledges that Producer and/or Company is photographing and recording such scenes in
express reliance upon the foregoing. The undersigned represents and warrants that the undersigned has all rights
and authority to enter into this agreement and to grant the rights granted hereunder.
Producer and/or Company are not obligated to actually use the Property or produce the Program or include the
Materials in the Program for which it was shot or otherwise. Producer and/or Company may at any time elect not to
use the Property by giving Owner written notice of such election, in which case neither party shall have any obligation
hereunder.
This is the entire agreement. No other authorization is necessary to enable Producer and/or Company to use the
Property for the purpose herein contemplated.
AGREED AND ACCEPTED:
BY: rfi
(P,;,tName) mecpn :iJllnClLr5
DATE:_b~/2~/~II__
