PRODUCTION SAFETY FORM (forms to be completed and on hand at every shoot)

University of New South Wales and the School of Arts and Media recognises as a primary responsibility its statutory obligations for the safety and well
being of all its employees and students and other persons at locations where University/business is being carried out. In fulfilling this responsibility the
university will act, so far as is reasonably practicable, in accordance with Section 28, Workplace Health and Safety Act, 1995 to ensure the health, safety and
welfare of all persons, including persons not formally associated with the university.
Students need to safeguard, so far as is reasonably practical, their own health and safety and that of others.
The purpose of the following three forms is to help identify hazards and ensure appropriate steps are taken to minimise risks in order to protect the health and
safety of university employees and anyone connected with the production.

PRODUCTION NAME:
INSIDE MIND
SUBJECT CODE: ARTS 3061
YEAR: 2016
FIRST AID/STUDENT SAFETY OFFICER: Ravi Shanmugarajah (938-57185)
SUPERVISING LECTURER: ENDA MURRAY / GREGORY DOLGOPOLOV
SHOOTING COMMENCING:
6 May 2016
SHOOTING FINISHED:
9 May 2016

LOCATIONS

SHOOTING
DATES

CLOSEST HOSPITAL/ MEDICAL

CENTRE TO LOCATION

ADDRESS

PHONE

SQUAREHOUSE 109

6 May 2016

Prince of Wales Hospital

Barker st, Randwick NSW 2031

(02) 9650 4000

ELECTRICAL
ENGINEERING
BUILDING

6 May 2016

Prince of Wales Hospital

Barker st, Randwick NSW 2031

(02) 9650 4000

APARTMENT

9 May 2016

The Hills Private Hospital

499 Windsor Road. Baulkham Hills NSW 2153

(02) 9639 3333

CAST AND
CREW NAMES

CONTACT
DETAILS

ANY KNOWN MEDICAL CONDITIONS CONTACT PERSON AND THEIR

CONTACT DETAILS IN CASE OF AN
EMERGENCY

VOLUNTEER
FORM submitted
for Non-Griffith
participants?

Abhi Dutta

(+61)426821024

None

Pompa Dutta 0403164884

Alexandra Duggan

(+61)408779044

None

Shaun Tamplin 0439848457

Delaney Loane

(+61)402234722

None

Cassidy Loane 0425277345

Jaimi Ward

(+61)418488744

None

Allan Ward 0418200603

Pamela Sujono

(+61)414208199

None

Indra Kurniawan 0466273042

Trudi Gultom

(+61)433330276

None

Umar Gultom 0452661706

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Sam Barrington

(+61) 488513683

None

Gill Barrington 00116479707783

Rose Marel

(+61) 405947888

None

Alan Marel 0414987765

Hazards must be identified before filming commences. The list below acts as a prompt for hazards additional to those you have identified yourself. When a
hazard has been identified you must perform a risk assessment. The producer should assess whether the risk is high, medium or low, and take appropriate
action to minimise the level of risk. The Risk Reduction/Action Form will be a record of your risk management.
REMEMBER: The health & safety of production members and the public must be protected by the establishment of a safe & controlled working

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HAZARD IDENTIFICATION/RISK ASSESSMENT

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HAZARD IDENTIFICATION
Tick if any of the categories are relevant

RISK
ASSESSMENT

Nil

Low/
Med

Human Factors

High

Locations and associated issues

Water in bathroom - girl holding

breath

Barefoot - could step on something

Water in bathroom - electricity ,

equipments near it

Lightbulb fall from ceiling near the

face

Heat emitted from the lightning place could sets on fire

Pills - chocking from gulping

Hallway - Slippery

Doors - Hands or things could get

squeezed in between wall and door

Small space - collision, there is a lot

of people

Dining room - slipper, cause of milk

!
HAZARD IDENTIFICATION
Tick if any of the categories are relevant

RISK ASSESSMENT

Nil

Low/Med

High

Hazardous substances, processes

Cars, Roads, Traffic

Travelling of 3 locations - organise
security for cast and crew travelling
late at night

Darkness - people not seeing trip hazards

Heat emitted from the lightning - people could

burn themselves

Props - things could move from shelves and

could fall

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Other Activites, work processes, props

Electricity, Lights & Cables

Jib, Dolly, Crane

Stunts / fight scenes

Power Generator
Outside Broadcasts

Night Operations

Props Making

Scenery Construction

Firearms/Weapons (includes toys/replicas)

Diving & Underwater Filming

Water Safety

Flying/Airports

Machinery

Cranes/Hoists, Fork Lifts & Access Platforms

Scaffolding & Working at Height

Special Effects
Working Overseas

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RISK REDUCTION/ACTION RECORD FORM

NOTE:
EVERY RISK IDENTIFIED ON THE HAZARD IDENTIFICATION/RISK ASSESSMENT MUST HAVE A CORRESPONDING ENTRY ON
THIS FORM. THIS FORM MUST BE COMPLETED AND SIGNED IN DUPLICATE. ONE TO BE RETAINED BY THE STUDENT PRODUCER AND ONE
TO BE RETAINED BY THE SUPERVISING LECTURER PRIOR TO PRODUCTION COMENCING.

!Things to remember when completing this form:

Ensure all fire and first aid precautions are identified.

Eliminate significant risks from chemicals, electricity, trip hazards, food and catering, lighting, lifting, water and working at height.
Clearly identify any expert help required and specialised equipment needed (e.g. an armourer/licensed shooter is required if any firearms
are to be deployed).

If you are unsure how to use this form, please seek advice from your lecturer.

RISK

PROPOSED ACTION

Water in bathroom electricity , equipments

near it

Be careful of the equipments and the electricity, not to

touch the water in the bathroom.

27 April
2016

Cool down the heat coming from the lights when it gets hot

27 April
2016

Hallway - Slippery

Wipe cloth to dry the floor

27 April
2016

Doors - Hands or things

could get squeezed in
between wall and door

Be careful with the doors

27 April
2016

Small space - collision,

there is a lot of people

Limit number of people per space

27 April
2016

Dining room - slipper,

cause of milk

Wipe cloth to dry the floor

27 April
2016

Heat emitted from the

lightning - place sets on
fire

Lecturer signature Producer signature and date

on plan

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Travelling of 3 locations
- organise security for
cast and crew travelling
late at night

Call security if needed for guidance

27 April
2016

Water in bathroom - girl

holding breath

A signal from the actor if she runs out of breath and take a
break first

27 April
2016

Barefoot - could step on

something

Clean the floor first

27 April
2016

Lightbulb fall from

ceiling near the face

Test the lightbulb hanging first, see if it is strong

27 April
2016

Pills - chocking from

gulping

Ask the actor/actress to slowly gulp down. If chocking

further happens, call the ambulance/police or perform
Abdominal thrusts

27 April
2016

Darkness - people not

seeing trip hazards

Have some lights turn on , light from phones or torches

could help people walk on the dark set.

27 April
2016

Cool down the heat coming from the lights when it gets hot

27 April
2016

Put the big objects away, and put the small objects near
the actors. First Aid available for the actor/actress if the
object hits them

27 April
2016

Heat emitted from the

lightning - people could
burn themselves
Props - things could
move from shelves and
could fall

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