TEXT: TM and ©2019 Monte Cook Games, LLC. Permission granted to duplicate for personal use.
  RPG CONSENT CHECKLIST
  GM Name:
  Player Name: (or leave blank)
  Planned Game Theme:
  If this game were a movie, its movie rating would be: G PG PG-13 R NC-17 Other: 
  Mark the color that best illustrates your comfort level with the following plot or story elements.
   
  Green = Enthusiastic consent; bring it on!
   
  Yellow = Okay if veiled or offstage; might be okay onstage but requires discussion ahead of time; uncertain. 
   
  Red = Hard line; do not include.
  HORROR ..............................................................
  Bugs ...............................................................
  Blood ..............................................................
  Demons .........................................................
  Eyeballs ..........................................................
  Gore ...............................................................
  Harm to animals ...........................................
  Harm to children ...........................................
  Rats ................................................................
  Spiders ...........................................................
  RELATIONSHIPS ...............................................
  Romance ........................................................
   
  Fade to black ............................................
   
  Explicit ......................................................
   
  Between PCs and NPCs  ..........................
   
  Between PCs.............................................
  Sex .................................................................. 
   
  Fade to Black ............................................
   
  Explicit ......................................................
   
  Between PCs and NPCs ...........................
   
  Between PCs ............................................
  SOCIAL AND CULTURAL ISSUES .................
  Homophobia ................................................. 
  Racism ...........................................................
  Real-world religion .........................................
  Sexism ............................................................
  Specific cultural issues ..................................
  MENTAL AND PHYSICAL HEALTH ..............
  Cancer ............................................................
  Claustrophobia ..............................................
  Freezing to death ...........................................
  Gaslighting .....................................................
  Genocide ........................................................
  Heatstroke  ....................................................
  Natural disasters (earthquakes, forest fires)  
   
  Paralysis/physical restraint ........................... 
  Police, police aggression ...............................
  Pregnancy, miscarriage, or abortion .............
  Self-harm ........................................................
  Severe weather (hurricanes, tornados) ........
  Sexual assault ................................................
  Starvation .......................................................
  Terrorism ........................................................
  Torture ............................................................
  Thirst  .............................................................
  ADDITIONAL TOPICS
  Do you want the GM to follow up with you to clarify 
  any of these responses? If so, which ones?
  G Y R
  G Y R
  ©2019 Monte Cook Games, LLC. Cypher System and its logo are trademarks of Monte Cook Games, LLC in the United States and other countries. Permission granted to duplicate for personal use.
  
SOURCE: textdata/thevault/_GM Books/Adventure prep and inspiration/Consent-in-Gaming-Form-Fillable-Checklist-2019-09-13.pdf