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UTAH NTSIP REPORTING FORM

REPORTING AGENCY CONTACT INFORMATION:


INCIDENT INFORMATION:

TIME:

LOCATION:
NOTE: If exact address is not known, enter cross streets, mile marker, township section range, latitude longitude

4. Geographical location of incident:

6. Where did the incident occur? Check one:

NOTE: Fixed facility answer questions 7-10, Transportation answer question 11-12

FIXED FACILITY:




DESCRIPTION OF SUBSTANCE(S) RELEASED


NOTE: Please complete the below sub-questions for each substance released or threatened to be released



SURROUNDINGS


15. Where did the release impact?

FACTORS CONTRIBUTING TO THE RELEASE


VICTIM(S)


NOTE: If more than one victim, complete the below sub-questions for each victim








H) Was the victim decontaminated?

EFFECTS OF RELEASE:


20. Was an official order an evacuation? (If yes, answer sub-questions)

A) List criteria for evacuation:
B) Total number officially evacuated:
C) Total hours the evacuation order was in effect:

21. Was in-place sheltering was ordered? (If yes, answer sub-questions)




For help, send a message to the NTSIP Specialist by clicking here.
3/11/2008