FORM 13-IAR

If a required field (indicated by *) does not apply to you, please enter N/A. You will not be able to proceed without doing so.

Incident/Accident Report Instructions

• This form must be completed by the Production Manager or his/her representative on set at the time the incident/accident occurred.
• Complete this form for every incident/accident/exposure that occurs on set, which results in injury or illness to a performer.

DETAILS ABOUT THE ON SET INCIDENT/ACCIDENT: (ensure “arising out of, and in the course of” the employment) Pain or discomfort that occurs at work is not necessarily work-related. The injury/disease must arise out of and be in the course of the performer’s employment. There must be a causal relationship between the onset of injury/disease with the performer’s work activities.

Production Information

Production Manager or Representative Completing this Form:

Production Location Designate Contact Information (if different from above):

Name of Person on Set to Whom the Incident/Accident was Reported

ACTRA Agreement Category

Performer Information

ACTRA Performer Category

Determination of an Incident/Accident on Set

The Accident on Set policy under which production participates may provide benefits to eligible performers when the performer is involved in an incident/accident/exposure that occurs while traveling directly to or from the production set to their usual residence.

Incident/Accident/Illness Definition *

Incident/Accident/Illness Details

Exact Location of Incident/Accident

Describe how the incident/accident occurred (specifics regarding actual event, body position, contributing factors such as weight of object if lifted. Description of the worker’s activities at the time of the onset). Upload additional pages and attach accident diagram, photographs, or additional information as required.

Object/equipment/substance inflicting Injury/Illness: (Upload measurements, draw diagrams, or take photos; if appropriate show location of employee, witnesses, and equipment/machinery/materials)

Details of the Injury

Describe any on set and/or off set medical treatment received.

Witnesses

Production should list the person(s) on set who witnessed the incident/accident and contact information. For each person listed, please also request a Witness/Medical Aid Contact and Consent Form from AFBS.