REPORTING AGENCY CONTACT INFORMATION:

Reporting agencies name:
Contact Person: Phone: Email:

INCIDENT INFORMATION:

TIME:
1. Date: 2. Start time: 3. End time:

4. Geographical location of incident:
Street address:
City: County: Zip code:

5. Name of business/industry where incident occurred: (if not a business/industry, enter “private household”)

6. Where did the incident occur? Check one: Fixed facility Transportation

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

FIXED FACILITY:

7. Number of people working the facility during the event:
8. Number of people visiting the facility during the event:
9. Describe the location within the facility where the event occurred:
10. List equipment involved in the event: (ancillary process equipment, piping, storage tank, etc.)

DESCRIPTION OF SUBSTANCE(S) RELEASED

Total number of substances reported
NOTE: Please complete the below sub-questions for each substance released or threatened to be released
A) Chemical or trade name of substance(s):
B) Was substance actually released, or threatened to be released:
C) Type of release: (spill, vapor, fire, explosion, etc.)
D) Quantity released: (specify units)

SURROUNDINGS

14. Weather conditions at time of the event:
15. Where did the release impact? Inside Outside Both

FACTORS CONTRIBUTING TO THE RELEASE

16. List the primary factor: (equipment failure, human error, intentional/illegal, weather etc.)
17. List the secondary factor: (improper mixing, system upset, maintenance, collision, improper loading, etc.)

VICTIM(S)

18. Number of people injured in this event:
Number of people transported to medical facility with no symptoms:

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

A) Category of victim: (employee, general public, police, student, etc.)
B) Severity of victim: (treated on scene, at hospital, death on scene, etc.)
C) Symptoms of victim: (respiratory irritation, dizziness, headache, etc.)
D) Level of Personal Protective Equipment (PPE) used by victim prior to incident: (level A, B, C, none, gloves, eye protection, etc,)
E) Sex of victim:
F) Age of victim:
G) Location of victim in relation to point of release:
H) Was the victim decontaminated? No Yes - at the scene Yes - at the medical facility

EFFECTS OF RELEASE:

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) Yes No
A) Level of restriction:
22. List any contamination from the release:
23. List all who responded to this incident:
24. List any activities taken to protect public health as a result of this event: (health advisory, health investigation, environmental sampling, etc.)
25. Please enter a brief synopsis of the event (200 words of less)