1. Risk Assessment Form – Part A
Reference:
Sign-off status
Not Required
Blank Template
[planning/approved etc]
Assessment summary details
Assessment title *
(Simple name for reference
purposes)
Recording opening scenes of a movie
Division:*
Netherhall School
Department:*
Media Studies
Series/ Prod/Unit:
Sticks and Stones
Programme/Area:
screenplay
Responsible
Manager:
Contact office:
Daniel Cooke
Tel: 07902824609
Address: 6 Rosemary
Greene Close Caxton Cambs
, CB23 3PS
Address/Tel:
Date assessment created
22/11/13
Address/Tel:
Confidential risk
assessment?
YES
Assessment Outline
(Summary of what is
proposed)
Assessment start
date
26/11/13
Review / End date
2/11/13
Country location
UK
Hostile / travel
advisory?
Location details
Owner: Malcolm Duffield
NB: If the country location selected is ‘Hostile’ you are
required to: complete the BBC Overseas High Risk
Assessment Form
Permissions written by
Malcom duffield
Crew / team
(Roles, responsibilities,
competencies)
N/A
Daniel Cooke- director/producer
Adam Duffield, Ryan Hawkins, Charlotte Hall – Actors
Lydia Sansom – Makeup artist
Attachments
(Detail supporting
documents)
Assessor(s)
*
Daniel Cooke
Assessor safety
competence
(Person drafting risk
assessment)
Date signed-off *
Authoriser(s) *
(Person responsible for
sign-off)
Distribution
(Who gets a copy of the
assessment)
Director and Producer , all crew
Data Protection Act: Personal information collected for the purposes of risk assessment will be used to identify those at risk, and
those involved in controlling risk, from this or similar activities and to fulfil the BBC's obligations under Health and Safety policy and
legislation. It will be retained for up to 6 years after the expiry of the activity. It may be shared with other organisations, including
our agents and contractors, with whom the risk or the control of risk is shared.
Activity and Hazard Summary
Activity
[This is a summary of the activities listed in part B of the risk assessment.]
Who Exposed
Hazards{hazard titles
Activity Risk Rating
Comments log
Who by
Date / time
received
[* mandatory fields]
Comments
Assessor response
Date/ time
responded

2. Risk Assessment Form – Part B
Reference:
6
Sign-off status
1
ACTIVITIES:
What are you doing, where, for how long and who will be
involved? Complete the fields in the form below).
Blank Template
[planning/approved etc]
HAZARDS & CONTROLS:
How could someone become hurt or made ill and
how are you going to prevent this from happening?
Activity Title:*
Riding a moped
Activity Description:
Riding a moped onto set multiple times with one person in the beginning then leaving set with three people on the back.
List those managing
this Activity and their
competence:
Daniel Cooke- CBT trained and owner of the moped
Who & how many are
at risk from this
Activity?
3 Actors
Hazards
How could someone become hurt or made ill
Control measures
How are you going to prevent this from happening?
Crashing the moped while in or out of motion
Efficient training to the rider of the moped and making sure that they are capable to ride it before
allowing them to attempt it.
Burning Yourself on the Exhaust/engine of the moped
Making sure that all actors and crew are aware of the heat that is produced and the risk of burn.
Risk Level*: After your controls have been applied what is your assessment of the risk level of
this activity?
Add additional activities as required – by copying this section and pasting below
[* mandatory fields]
Medium

3. Risk Assessment Form – Part B
Reference:
6
Sign-off status
2
ACTIVITIES:
What are you doing, where, for how long and who will be
involved? Complete the fields in the form below).
Activity Title:*
[planning/approved etc]
HAZARDS & CONTROLS:
How could someone become hurt or made ill and
how are you going to prevent this from happening?
Firing a gun
Activity Description:
Firing a bb gun /air pistol off camera.
List those managing
this Activity and their
competence:
Daniel Cooke – Owner of Pistol
Adam Duffield – Owner of Air Pistol
Who & how many are
at risk from this
Activity?
All Crew and Actors ( 3 Actors and 2 crew)
Hazards
How could someone become hurt or made ill
Control measures
How are you going to prevent this from happening?
Accidental firing of hand gun (BB).
Make sure that the guns are not unnecessarily loaded with ammo.
Risk Level*: After your controls have been applied what is your assessment of the risk level of
this activity?
Add additional activities as required – by copying this section and pasting below
[* mandatory fields]
Blank Template
Low