Form 4- Serious Incident Reporting Procedures - Safety On The Set
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1SERIOUS INCIDENT REPORTING PROCEDURES
Incidents that result in transportation by ambulance, visitation to the hospital by one or more employees, any treatments other than
general first aid, or any serious property/asset damage, must be reported as follows:
Unit Production Manager Responsibilities:
1.
In the event of a serious accident, injury or mishap, AFTER ALL NECESSARY EMERGENCY PERSONNEL ARE CALLED, the
LINE PRODUCER should contact the PRODUCTION EXECUTIVE WITHOUT EXCEPTION.
Name: _________________________________ Office: ___________________ Cell: ____________________
After discussion with your Production Executive and with her/his instruction, the following people will be notified:
Production Safety Consultant: Name: ________________________ Office: _____________ Cell: _____________
Risk Management Representative: Name: ________________________ Office: _____________ Cell: _____________
Labor Relations Attorney:* Name: ________________________ Office: _____________ Cell: _____________
Worldwide Communication/ Publicity Executive: Name: _____________________ Office: ___________ Cell: ___________
*Under the union collective bargaining agreements, union notification is required of any injury, regardless of the severity.
If the incident occurred within the State of California and resulted in serious injury, death or illness to an employee, Cal-OSHA must
be notified within eight (8) hours of the incident. Other Countries, States and Provinces have their own reporting requirements.
Regardless of where you are filming, the Production Safety Consultant will make these notification calls.
2.
Information which is required to be reported:
Time and date of accident.
Employer's name, address and telephone number.
Name and job title of person reporting the accident.
Address of site of accident or event.
Name of person to contact at accident site.
Name and address of injured employee(s).
Nature of injury.
Location where injured employee(s) was (were) moved to.
List and identities of other law enforcement agencies present at the accident site.
Description of accident and whether the accident scene has been altered.
NOTE: Any employer, officer, management official or supervisor who knowingly fails to report a death to Cal-OSHA or knowingly induces
another to do so is guilty of a misdemeanor and will face a penalty of up to one year in jail, a fine of up to $15,000, or both. If the violator
is a corporation or a limited liability company, the corporation or company could be fined up to $150,000.00.
3.
For serious accidents as defined above, the Production Safety Consultant will direct you to complete an Accident Investigation
Report (Form 9). The completed report should be sent to the Production Safety Consultant and Risk Management.
4.
Any accident should be noted on the back of the Production Report on the date the accident occurred by identifying only the name of
injured employee and classification.
CAUTION:
Written and/or verbal statements should not be taken unless authorized by the Studio Legal Department.
Speculation
regarding the cause(s) of accident(s) are not to be included as part of any Accident/Incident Investigation Report (Form 9). Speak with
your Production Safety Consultant for direction.
Set Medic/First Aid Attendant Responsibilities:
1.
Notify the Line Producer of the injury.
2.
Provide the patient with Workers’ Compensation Form or local equivalent. (The patient must sign and date a receipt. If the patient
refuses the form, be sure to document this in your notes.)
3.
FAX completed forms to the appropriate Workers’ Compensation Department:
a.
Warner Bros.: (818) 977-6787
b.
Cast & Crew: (818) 848-4614
c.
Entertainment Partners: (818) 559-3283
d.
Production Safety Representative: (818) 954-2805
SEND a completed copy of the form to your Production Executive with that day's production report.
4.
5.
Fill out Employer’s Report of Occupational Injury or Illness (Form 5020) or local equivalent. Record the patient’s recounting of
events in quotes. DO NOT SPECULATE.
6.
FAX completed Form 5020 (or local equivalent) to the Production Safety Consultant at (818) 954-2805.
7.
Complete a Refusal of First Aid form if the employee refuses to be treated at the scene of the incident or transported to the hospital.
Under the guidance and direction of the Studio Legal Department, the Production Safety Consultant
will conduct any additional accident investigations necessary.
Form 4 – Serious Incident Reporting Procedures
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