Emergency Forms

[centaura]

Re the first aid thing:

I have all cast and crew submit a CONFIDENTIAL Emergency Medical form

I will give this statement a resounding "I AGREE"  I will not go past day one of working with a group of actors without a Emergency Med info form!  I've already had three cases of having to take a comatose or non-sensical person to an emergency room, and in each case I was able to hand their form straight to the emergency staff personel.  

Even if the person is totally coherent, I find its still helpful, especially if I have lines for their health insurance information, which most folks don't know off the top of their heads.

-Centaura


thread edited by nmno. was originally part of "Leaving the booth..."[/i]

[smejs]

I too use an emergency info sheet.  I take it a little further than some folks, and make it a 2 page document with a heck of a lot of information on it.  I ask if they have a car they've brought and the license plate number.  I ask them to list any PRE-PLANNED conflicts agreed to in contract with the theatre (this has saved both mine and the producer's butt before),  As for actual medical, I include what dietary restrictions (including vegetarian - so if theatre has to provide food you already know); emergency contact person and their relation; health insurance company, group mumber, and policy number; a general line saying "Please list any medical problems, conditions, or concerns a doctor should be aware of when treating you"; and another of "Do you have any significant medical history?  If so, please describe,;" and ask if they wear contact lenses or corrective lenses of any kind.  Final line of document is "ALL INFORMATION IN THIS SHEET WILL BE KEPT CONFIDENTIAL.  THE INFORMATION IS NECESSARY IN THE EVENT OF A MEDICAL OR PERSONAL EMERGENCY SHOULD YOU NEED TREATMENT WHILE WORKING AT INSERT NAME HERE THEATRE."

Erin

[Mac Calder]

Here is a rough text version of my medical sectionthat will give anyone an idea of what I ask for - the first day is actually 4 pages requesting a variety of things, including approximate sizes for costumes and a listing of grievences.

Code: [Select]


Surname: ________________  First name:_______________ Initials:____
Phone Number: (__)___________
Mobile Number: (__)___________
Email Address: ___________@______________
Home Address:___________________________
                      ___________________________
                      ___________________________
Date Of Birth: __/__/19__

**MEDICAL INFORMATION**
Information provided below is strictly confidential, and will be destroyed on closing night. This information will not be shared, except in an emergancy, and then only with trained medical professionals.

Do you suffer from any of the following (Please circle)

Allergies      Eppilepsy     Asthma     Diabetes     Heart disease

Other:______________________________________________

Symptoms of an eppisode:_____________________________
___________________________________________________

Course of action to be taken: ___________________________
____________________________________________________
____________________________________________________

Please circle any of the following that apply to you:

Vegetarian    Lactose intolerant    Food alergies (please list)

___________________________________________________


Prefered Doctor: ______________________________________
Contact Number: ______________________________________

Emerganct contact (this information is required for consent to medical
treatment in cases where you are unable to give consent)

Name: ________________
Home Phone: (__)_________________
Work Phone: (__)_________________
Mobile: (__)___________________
Relationship:___________________

If the above mentioned person is unreachable, if you wish for STAGE MANAGERS NAME to be allowed to give consent, please sign the statement below:

I _____________ give consent for STAGE MANAGERS NAME to give consent for any treatments of a medical nature to be carried out upon my personage whilst I am employed by the COMPANY NAME for the production of PRODUCTION NAME, should I not be able to give consent, and the above mentioned person be un-reachable. I understand that STAGE MANAGERS NAME will act according to any wishes I have expressed to him/her in relation to this course of action.

SIGNATURE
DATE


[i]This form is highly confidential and will be destroyed after the production has finished. All fields on this form in the medical section are optional. STAGE MANAGERS NAME will not show this form in any way or use it's contents in a negative fasion. We suggest that all members of the cast and crew fill this form out to the best of their knowledge.[/i]

[loebtmc]

I do basically the same thing, a 1-page emergency info document that everyone fills out w home address and phone, their pertinent medical history and any insurance info, and emergency contact. This also allows me to do the final contact sheet in the first week of rehearsal, saving a ton of time at the end when I am just plain ol' NOT IN THE MOOD.

I add one line at the bottom of the page for birthday, so I can set up a calendar for the run and we can get cards and whatever to help celebrate. Esp on long runs, excuses for events are much needed!

[hbelden]

It should be mentioned in this thread that you have to be aware of your local relevant laws...  it's my understanding that in California it is against the law to ask employees (which is what the state considers actors, and you their manager) about their medical history.  All I ask for on my medical form is their insurance, two emergency personal contacts (at least one local), the name and number of their physician, and if they have any first aid, CPR, or medical training.

When materials are used that people could have allergies to, I'm supposed to post that information for everyone to look at.  For example, the ingredients of the prop sandwich or the brand name of the laundry detergent that wardrobe uses.  But that won't keep actors from eating peanut butter sandwiches if their scene partner is allergic to peanuts, so I'm at a loss as to what to do in that case.

[Mac Calder]

Is it illegal to ask, or is it illegal to require - I know over here that it is illegal to require someone to give a medical history, but it is not illegal to hand out a form asking if they could provide details.  If you hand out a form that is non-compulsary, the information they provide is then voluntarily given, instead of making it seem like an inquest into their medical background. The one thing you never do is get a medical form done at an audition, as it can then be considered medical screening and opens doors for law suits.

I would check with someone about whether you can distribute a form with something like this up the top:

"The contents of this form are completly confidential, and all information (with the exception of emergency contact) are entirely optional."

99% of people will be straight with you and list what you need to know, the other 1% are the people who dont hand the form back in becuase they forgot about it.

In many ways I find the limitations on medical checks quite irresponsible. There are certain things which need to be managed properly in certain events  - I had a cast member seriously injure their knee for example and he was unconcious - it turns out he was a haemophiliac. He did not clot. I was lucky that he had told me when we started rehearsals, and he told me how to properly deal with it if something should happen. I was prepaired, and when I rang 000 (aka 911 to you yanks ;-)) I could advise them as well and the ambulance came prepaired. If he had not told me, I would not have known, and he probably would have bled out (we could not get onto his emergancy contact until the next day) as they took him to hospital. I believe it is the employers responsibility to make sure that their workplace is safe to everyone, and that means asking the right questions - and it is the employees responsibility to provide the answers. All under a strict banner of confidentiality.

[sam_the_man]

I would Add the following::

Code: newbielink:javascript:void(0); [nonactive]

Emergency contact
(This information is required for consent to medical treatment in cases where you are unable to give consent)
Name: __________________________________
Home Phone: (__)_________________  Work Phone: (__)_________________  Mobile: (__)___________________
Relationship:_______________________

If the above mentioned person is unreachable, if you wish for INSERT SM'S NAME HERE to be allowed to give consent, please sign the statement below:

I _________________________ do hereby give my consent to INSERT SM'S NAME HERE to secure and authorize any such emergency medical treatment, as the above name might require while at a Rehearsal and (or) Performance where INSERT SM'S NAME HERE is present and acting under the title of Stage Manager, during _____________________________ production, and produced by ____________________. I also agree to pay all the costs and fees that may accrue with emergency medical care or treatment that is authorized by Sam Mackey.  I release, absolve, and indemnify INSERT SM'S NAME HERE from all risk and hazards associated with the activities and in the event of injury, do expressly wave all clams against INSERT SM'S NAME HERE.

SIGNATURE _______________________________________________________________      DATE __________
(IF UNDER 18, PARENTAL / LEAGAL GUARIDAN SIGNATURE)
SIGNATURE OF MINOR________________________________________________

It just states that they cant sue you if you make a medical choice that they dont agree with later on.   I copyed it from an actor contract from a past show that was produced by a major town goverment,  so I *think* it could stand up in a court of law.  But I am NOT SURE!
[/code]

[sam_the_man]

I would Add the following::

Code: newbielink:javascript:void(0); [nonactive]

Emergency contact
(This information is required for consent to medical treatment in cases where you are unable to give consent)
Name: __________________________________
Home Phone: (__)_________________  Work Phone: (__)_________________  Mobile: (__)___________________
Relationship:_______________________

If the above mentioned person is unreachable, if you wish for INSERT SM'S NAME HERE to be allowed to give consent, please sign the statement below:

I _________________________ do hereby give my consent to INSERT SM'S NAME HERE to secure and authorize any such emergency medical treatment, as the above name might require while at a Rehearsal and (or) Performance where INSERT SM'S NAME HERE is present and acting under the title of Stage Manager, during _____________________________ production, and produced by ____________________. I also agree to pay all the costs and fees that may accrue with emergency medical care or treatment that is authorized by Sam Mackey.  I release, absolve, and indemnify INSERT SM'S NAME HERE from all risk and hazards associated with the activities and in the event of injury, do expressly wave all clams against INSERT SM'S NAME HERE.

SIGNATURE _______________________________________________________________      DATE __________
(IF UNDER 18, PARENTAL / LEAGAL GUARIDAN SIGNATURE)
SIGNATURE OF MINOR________________________________________________

It just states that they cant sue you if you make a medical choice that they dont agree with later on.   I copyed it from an actor contract from a past show that was produced by a major town goverment,  so I *think* it could stand up in a court of law.  But I am NOT SURE!


(There are major spelling probs. in the above)
[/code]

[smejs]

and in the event of injury, do expressly wave all clams against INSERT SM'S NAME HERE.
-snip-
(There are major spelling probs. in the above)

Aw, come on, everyone, wave a clam!  They don't get much excitement in those little shells!  :lol:

Erin

[lbeacham]

I'm a recent California transplant, and have run into the same problem. (Which, since it's a new national privacy law, I'm not sure why I wasn't aware of it in Illinois, Florida or Texas, but, whatever.)  From what I've been able to determine after reading countless HIPPA official websites, primarily, the HIPPA regulations only apply to medical facilities and institutions, but just to protect myself, I've added this to the top of the sheet:

Due to current HIPAA regulations, please be aware of  the following:
•  All information will be kept strictly confidential, in the possession of the Stage Manager.  This information will be destroyed at the end of the term of your contract to protect your privacy.  
•This information will only be used in case of a medical emergency
•This form can NOT be used as a medical consent form, OR without your consent.
•All information that you provide is strictly on a voluntary basis.  

I also ask for
In The Event Of an Emergency, Please Notify:
NAME:                  
PHONE NUMBER:               
ADDRESS:                  
RELATIONSHIP:                           
Allergies Or Other Medical Conditions, Prescription Medications, Dietary Restrictions/ Allergies, or Other Information Someone Treating An Emergency Should Know:   

ALSO PLEASE COMPLETE THE BELOW:         
(If Applicable)
Agent’s Name:               
Agency Name:            
Agency Phone:         
Agency Address:                           
I've been in situations where an actor's emergency contact wasn't available, the actor was unconscious, and the only person who had the actor's medical info was their agent.  Since then, I've always asked for the info.  It's always good to have their contact info available.  I don't ask for permission on the sheet, since permission is implied if 911 ever needs to be called.  

There's my 2 cents for the day.

[ljh007]

I also like to ask for local address info in these forms. If artists/crew are from out of town, it is essential to know what hotel they're staying at. If necessary, you can send medics (or interns) to their room to get any important medicine/supplies. I also ask for permanent address, for reference.

[PSMKay]

There is a simple starter Emergency Contact form that I used to use available in the Uploaded Forms forum. 

http://smnetwork.org/forum/index.php?topic=1090.msg6407#msg6407

[ESM_John]

At my highschool....we obviously dont have to worry as much about lawsuits and all that but teenage actors and soda sometimes lead to people falling of stairs, running into pipe ends, etc. So we have a little emergency contact sheet (secretly meant for "Rehearsal started...where are you calls) and we get copies from the office of the actual medical info as well.

Thankfully weve never really had to use it.

[Tigerrr]

Interesting.  Up here in Canada, when we get our deputy package in the mail, Equity sends a Voluntary Emergency Medical Form that we just photocopy and hand out on the first day.  Saves all the legal questions - it came from head office therefore no worries.  Been done that way for years as far as I know (still a bit new to Equity).  I suppose AEA doesn't send something similar?

[MatthewShiner]

I don't think American AEA sends out forms due to the fact state laws are so different.

I do ask for the basics (Allergies/medication/medical conditions we should know about it), insurance and doctor information, Emergency contact and that's about it.