Download as doc, pdf, or txt
Download as doc, pdf, or txt
You are on page 1of 2

PRODUCTION TITLE: Old Town SHOOT DATE/S: October

PRODUCTION OFFICE PHONE/MOBILE: 0!!"#$%0"


LOCATION THIS FORM RELATES TO: &'()*+de, -re(t .(r/o't0
Co/1lete t0e 2ollow+n3 t(ble r(t+n3
e(c0 r+*4* *e5er+t) on *c(le 2ro/ Ne3l+3+ble 6N7, Low r+*4 6L7, Moder(te r+*4 6M7, Se5ere 6S7, 8er) *e5ere 687
e(c0 r+*4* l+4el+0ood on *c(le 2ro/ 8er) 'nl+4el) 68U7, Unl+4el) 6U7, Po**+ble 6P7, L+4el) 6L7, 8er) l+4el) 68L7
Deter/+ne t0e r+*4 2(ctor 2ro/ t0e t(ble o5erle(29
H(:(rd Pre*ent; Se5er+t) L+4el+0ood R+*4 F(ctor
% Alco0ol/dr'3*
< An+/(l*/+n*ect*
$ A'd+ence*
# C(/er( c(ble/3r+1 e='+1/ent
! Con2+ned *1(ce*
" Derel+ct b'+ld+n3*/d(n3ero'* *tr'ct're* > < <
Electr+c+t)/3(* 6ot0er t0(n nor/(l *'11l+e*7
? F(t+3'e/lon3 0o'r*
@ F+re/2l(//(ble /(ter+(l*
%0 H(:(rdo'* *'b*t(nce*
%% He(t/Cold/eAtre/e we(t0er
%< L(*er/*trobe e22ect*
%$ M(c0+ner)/+nd'*tr+(l/ cr(ne/0o+*t
%# M(ter+(l* B 3l(**, nonB2+re ret(rd(nt *et /(ter+(l*
%! N+30t o1er(t+on
%" No+*e C 0+30 *o'nd le5el*
% Non *t(nd(rd /(n'(l 0(ndl+n3
%? P'bl+c/crowd* > % < <
%@ R(d+(t+on
<0 Sc(22old/Ro*tr(
<% S/o4+n3 on *et > < % <
<< S1ec+(l e22ect*/eA1lo*+5e*
<$ S1ec+(l need* 6elderl), d+*(bled, +neA1er+enced7
<# S1ec+(l+*ed re*c'e/2+r*t (+d
<! St'nt*, d(n3ero'* (ct+5+t+e*
<" T(ll *cener)/*'*1ended ce+l+n3*
< 8e0+cle*/*1eed
<? D(ter/1roA+/+t) to w(ter
<@ De(1on*
$0 Dor4+n3 (t 0e+30t*
$% Dor4+n3 o5er*e(*
$< Ot0er r+*4*
C(lc'l(te t0e R+*4 F(ctor:
8er) Unl+4el) Unl+4el) Po**+ble L+4el) 8er) L+4el)
8er) *e5ere $ # # ! !
Se5ere < $ $ $ !
Moder(te < < $ $ $
Sl+30t % < < $ $
Ne3l+3+ble % % < < $
Dec+de t0e (ct+on to t(4e:
! 8er) *e5ere T(4e +//ed+(te (ct+on
# Se5ere H+30 1r+or+t)
$ Moder(te R+*4 Pro3r(//e 2or (ct+on
< Low R+*4 Act+on /() be re='+red
% Ne3l+3+ble Prob(bl) (cce1t(ble
T0en l+*t e(c0 r+*4 +dent+2+ed
H(:(rd no: " R+*4 F(ctor 6%B!7 <
L
O
C
A
T
I
O
N

R
I
S
K

A
S
S
E
S
S
M
E
N
T

F
O
R
M
H(:(rd no: <% R+*4 F(ctor 6%B!7 <
De*cr+1t+on Prot(3on+*t w+ll be */o4+n3 to (dd to o5er(ll 2eel o2 t0e /'*+c 5+deo9 A*+de 2ro/
ob5+o'* lon3 ter/ 0e(lt0 d(/(3e, /+n+/(l r+*4 on *et (* not0+n3 2l(//(ble9
Per*on6*7 eA1o*ed 6det(+l +2
c(*t/crew 6C7, o't*+de
co/1(n) 6O7 or 1'bl+c 6P7 7
Prot(3on+*t
Act+on to t(4e En*'re *(2et) w0en l+30t+n3 (nd */o4+n3
Per*on/co/1(n) re*1on*+ble
2or (ct+on
%
To be co/1leted (t (3reed l(ter d(te B
EA1o*ed 1er*on6*7
+n2or/ed; 6)/n7
. A3reed (ct+on t(4en; 6)/n7 . R+*4 re/o5ed; 6)/n7 .
H(:(rd no: %? R+*4 F(ctor 6%B!7 <
De*cr+1t+on D+ll be 2+l/+n3 /e/ber* o2 t0e 1'bl+cE* 2eet w(l4+n3 +nto *1(ce*
Per*on6*7 eA1o*ed 6det(+l +2
c(*t/crew 6C7, o't*+de
co/1(n) 6O7 or 1'bl+c 6P7 7
P
Act+on to t(4e /
Per*on/co/1(n) re*1on*+ble
2or (ct+on
%
To be co/1leted (t (3reed l(ter d(te B
EA1o*ed 1er*on6*7
+n2or/ed; 6)/n7
. A3reed (ct+on t(4en; 6)/n7 . R+*4 re/o5ed; 6)/n7 .
Co1) (nd 1(*te t0+* t(ble 2or e(c0 o2 t0e 0(:(rd*, t0en 3et t0e 2or/ *+3ned9 I2 t0e 1rod'cer 0(* not co/1leted
t0e r+*4 (**e**/ent, t0en t0e) *0o'ld co'nter*+3n t0+* 2or/9
Co/1leted b): Fr(*er D0+te Po*+t+on:
S+3n(t're: Fraserhite D(te:
Co'nter*+3ned b): PRODUCER
S+3n(t're D(te:

You might also like