[* mandatory fields]

Risk Assessment Form – Part A Blank Template

Reference: [006] Sign-off status [approved]

Assessment summary details

Assessment title * (Simple name for reference purposes)

Music Video

Division:* Production Department:* Media

Series/ Prod/Unit: Closer Programme/Area:

Responsible

Manager: Jack Murphy Contact office:

Address/Tel: Address/Tel:

Date assessment created 26/11/12 Confidential risk assessment?

NO

Assessment Outline

(Summary of what is proposed)

I am proposing to film in a first just outside of Bartlow and in a bedroom in Bartlow.

Assessment start

date 7/12/12 Review / End date 9/12/12

Country location England Hostile / travel

advisory?

Location details Bartlow Forest Bartlow

NB: If the country location selected is ‘Hostile’ you are required to: complete the BBC Overseas High Risk Assessment Form

Crew / team

(Roles, responsibilities, competencies)

Kora Faithfull (main protagonist), Izzy Lapsatis (Lead Singer), Aaron Peters (Guitarist), Jacob Waldman-Khaira (Bassist), Tom Brice (Drummer), Jack Murphy (Director, Cameraman), Ashlie Perry (Makeup artist)

Attachments

(Detail supporting documents)

Assessor(s) *

(Person drafting risk assessment)

Jack Murphy Assessor safety competence

Authoriser(s) *

(Person responsible for sign-off)

Mr Sheppard Date signed-off *

Distribution

(Who gets a copy of the assessment)

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 [This is a summary of the activities listed in part B of the risk assessment.]

Activity Who Exposed Hazards{hazard titles Activity Risk Rating

Inactive Machinery Everyone Machinery 1

Comments log

Who by Date / time received

Comments Assessor response Date/ time responded