Hazardous Substances Emergency Events Surveillance

Form Approved
OMB No. 0923-0008
Exp.Date 05/31/2008

HAZARDOUS SUBSTANCES EMERGENCY EVENTS SURVEILLANCE
DATA COLLECTION FORM

Public reporting burden of this collection of information is estimated to average 45 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24,
Atlanta, Georgia 30333; ATTN: PRA (0923-0008).

Hazardous Substances Emergency Events Surveillance (HSEES)

DATA COLLECTION FORM
NOTE: The response choice of unknown/-9 has been deleted from the form because of
CDC/ATSDR standards.
EVENT IDENTIFICATION AND NOTIFICATION
1.

Event Identifier
__ __ __ __ __ __ __ __ __ __
Enter the ten character identification code of the event. (The code will be generated by
the computer once the necessary information is entered into the system.)

2.

Date that this event was entered into the HSEES system.
(This will be generated by the computer.)

3.

Based on the HSEES protocol, is this event eligible to be entered into the surveillance
system?

__ __ -__ __ -__ __ __ __

An event is a release of any hazardous substance except petroleum in an amount that
needs to be removed, cleaned up, or neutralized according to federal, state, or local law.
Threatened releases of such substances are also included if this threat led to an action
(e.g., evacuation) to protect public health.
1 = Yes
2 = No
If “No” was selected, please choose one of the following reasons why:
[1] Hoax
[2] Petroleum
[3] Small quantity
[4] Chronic
[5] Insufficient information
[6] Not a hazardous substance
[7] Controlled/legal/permitted release
[8] Duplicate
[A] No release, no public health action
[B] Suspicious activity (potentially terrorism)
[C] Not a potential HSEES event (HSEES just being used to capture data)
4.

Were the substances associated with this event (This will be generated by the computer
afterQ30 has been answered for all chemicals released in the event)
1= All actually released into environment.
2 = All threatened to be released into environment.
3 = Some actually and some threatened to be released.
2

5.

Date that the state HSEES staff was notified of the event.

__ __ -__ __ -__ __ __ __

6.

Notification Contact (Who first notified the state health department?)
[0] Media
[1] On scene commander/incident commander or staff (e.g., fire, police, EPA)
[2] Health agency other than the state health dept
[3] Medical facility (or poison control center)
[4] Environmental department or division
[5] Emergency government/emergency services
[6] Citizen or citizen's group
[7] Owner/operator of facility, vehicle, or vessel
[8] Other _______________(15)
[9] Unknown
[A] DOT/HMIS and ERNS
[B] Other government agency
[C] Other program within state health department

7.

Contact information (OPTIONAL for data entry. This information is encrypted.)

DESCRIPTION OF EVENT
8.

What was the date of this event? (MM/DD/YYYY) __ __ -__ __ -__ __ __ __
(This will be generated by)
drop box to select year [ year] and then select month [month] which produces a monthly
calendar to select the day.

9.

On what day of the week did this event occur? (This will be generated by the computer.)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

10.

What time did the event start?
____ ____ : ____ _____
(Not when you were notified. Use 24-hour time format (e.g., 15:59). If unknown, leave
blank and select a time category. If time category unknown, leave blank. If exact time is
entered, the computer will automatically fill in the time category.)
1 = 00:00 am - 05:59 am
2 = 06:00 am - 11:59 am
3 = 12:00 pm - 05:59 pm/12:00-17:59
4 = 06:00 pm - 11:59 pm/18:00-23:59

3

11.

Were multiple locations contaminated during this event [ ] Yes [ ] No

12.

EVENT LOCATION
Where did the event start? (If exact street address is not known, enter cross streets,
highway mile marker, railroad crossing etc.)
___________________________________________________________________
Street address (encrypted)
______________________
City

_____(2)
State

______________________
County
_________(5)
Zip Code
Enter decimal or degrees/ minutes/seconds
Longitude:

13.

____ o ____ '___. ___ "

Latitude:

____ o ____ '___. ___ "

degree-to-decimal

degree-to-decimal

___.___

___.___

EVENT LOCATION NAME
_________________________________________________________________
Name (encrypted)
___________________________________________________________________
Type of industry (NAICS first if available)

14.

Is the industry listed in Question 13 the same as the industry (or entity) that caused the
hazardous substance(s) release?
1 = Yes (Go to #16)
2 = No

15.

________________________________________________________
Type of Industry or entity that caused the release (NAICS first if available)

4

16.

Were any of the following within a 1/4 mile of the event? (Select all that apply.)
Residence
Yes
No
School
Yes
No
Hospital
Yes
No
Nursing home
Yes
No
Licensed daycare
Yes
No
Industry or other business
Yes
No
Recreational area
Yes
No

17.

What is the general land use in the surrounding area? (May have ONE or TWO entries.)
[0] Undeveloped area
[1] Industrial area
[2] Commercial area
[3] Residential area
[4] Agricultural area
[A] Military facility/DOE/DOD
[C] Recreational area

18.

What were the general weather conditions at the time of the event? (May have ONE or
TWO entries.)
[1] Clear skies (no extreme weather conditions)
[2] Rain
[3] Snow, ice, sleet, hail
[4] Fog or mist
[7] High winds
[8] Other _______________(15)
[A] Weather disasters (hurricane, tornado, flood)
[B] Extreme heat
[C] Extreme cold
[D] Lightning

19.

What type of event was this?
[1] Transportation
[2] Fixed facility (Go to #22)

20.

What mode of transportation was involved? (May have ONE or TWO entries.)
[2] Ground (drop box to choose tanker truck, non-tanker truck, van, automobile, bus,
other)
[3] Rail (drop box to choose container on flat car, tank car, box car, other)
[4] Water (drop box to choose container ship with own power, tanker ship with own
power, barge towed by other vessel, other)
[5] Air (drop box to choose crop duster, cargo plane, passenger plane, other)
[6] Pipeline

5

21.

What phase of transportation was involved?
[1] occurred during unloading of a stationary
vehicle or vessel (Go to # 25)
[2] from a moving vehicle or vessel (Go to #25)
[3] en route that was later discovered at a fixed facility (Go to #25)
[4] occurred from a stationary vehicle or vessel (e.g., staged at a transfer station) (Go to #25)
[8] Other _______________(15) (Go to #25)

22.

What area/equipment of the fixed facility was involved in the event? (May have ONE or
TWO entries.) (Answer for NAICS categories “21” Mining, “22” Utilities, “23”
Manufacturing only)
[0] Transportation within fixed facility
[2] Process vessel
[3] Piping
[4] Material handling area (i.e. loading dock)
[5] Storage area above ground (i.e. warehouse, tank, storage shed)
[6] Storage area below ground
[7] Dump/waste area (i.e. sewer)
[8] Other
[A] Ancillary process equipment
[B] Transformer or capacitor
[C] Incinerator
[D] Heating/cooling for building
[J] Laboratory
(After an area/equipment is selected, a drop box text field will be available to further
specify the area or equipment. If “other” is chosen, you should enter additional
information in the text field.) _________________________________ (15)

23.

Number of people working the facility during the event?

__ __ __ __

24.

Number of people visiting the facility during the event?

__ __ __ __

25.

Factors contributing to the release: (If primary factor is unknown leave blank. If there is
no secondary factor, then select choice N)
Primary:
[2] Equipment failure
[3] Human error
[8] Other _______________(15)
[G] Intentional
[S] Illegal act
[H] Bad weather conditions/natural disasters

Secondary:
6

[1] Improper mixing
[2] Equipment failure
[3] Human error
[4] Improper filling, loading, or packing
[8] Other _______________(15)
[A] Performing maintenance
[B] System/process upset
[C] System start up and shutdown
[E] Power failure/electrical problems
[F] Unauthorized/improper dumping
[I] Vehicle or vessel collision
[J] Fire
[K] Explosion
[L] Overspray/misapplication
[N] No secondary factor
[O] Load shift
[P] Vehicle or vessel derailment/rollover/capsizing
[Q] Illicit drug production related
[R] Forklift puncture
26.

Did the release impact:
1 = Inside a closed structure only
2 = Outside of a closed structure only
3 = Both inside and outside of a closed structure

DESCRIPTION OF SUBSTANCE(S)
27.

What is the total number of chemicals reported for this event?
__ __ __
(Questions 28-36 need to be answered for each substance involved in the incident. Use
additional pages and record comparable information for each substance.)

28.

Chemical number (Assigned by computer, 1..n)

29.

Chemical or trade name of substance
____________________________________________________________________(37)

__ __ __

Edit (This enables Questions 29, 31 &33)
[ ] Individual
[ ] Mixture
[ ] Reaction

30.

Was the substance
7

[1] Actually released into the environment.
[2] Threatened to be released into the environment.
31.

32.

33.

Type of substance
[1] Chemical
[2] Radiological
[3] Medical
[4] Biological
Was this substance used as a pesticide (a substance not classified as a pesticide, but being
used in that capacity)?
[1] Yes
[2] No
Provide identification information if the chemical name is not on the pick list.
Chemical Abstract Service (CAS) number ______________
Department of Transportation (DOT) United Nations (UN) number __________
Manufacturer/other information _____________________________________________
Substance Category _________________________________________________

34.

Type of release (May have ONE or TWO entries.)
[1] Spill (liquid or solid)
[2] Volatilization/aerosolized (vapor)
[3] Fire
[4] Explosion
[5] Radiation
[7] Not applicable, threatened release

35.

Quantity released
__ __ __ __ __ __. __
(Enter a numeric value. If unknown, leave blank and enter the category for the amount
released. The category will automatically be filled in by the computer if exact amount is
entered. If category is unknown, leave blank)
A = <1
B = 1- <10
C = 10- < 100
D = 100- < 500
E = 500 - < 1,000
F = 1000 - < 10,000
G = 10,000 +

36.

Unit of measure (to complete question 35).
8

[1] Pounds
[2] Kilograms
[3] Gallons
[4] Liters
[5] Cubic feet
[6] Ounces by volume
[7] Milliliters
[8] Pico curies
[A] Tons (metric)
[B] Ounces by weight
[C] PPM (parts per million)
MORBIDITY AND MORTALITY
37.

How many people were transported to a medical facility for a check-up
or observation but did not have any symptoms
(i.e., do not meet the definition for a victim of the event)?

__ __ __ __

38.

How many people were injured in this event (number of victims)? __ __ __ __
(If none enter 0 and skip to Q40 - decon.)

39.

Complete Table 1 for the victims using the following codes. Complete all items
(columns) for each victim.
Column "A" Category of victim
[1] Employee
[2] Responder (not specified)
[3] General public
[A] Career firefighter
[B] Volunteer firefighter
[C] Firefighter (not specified)
[D] Police officer
[E] EMT personnel
[F] Hospital personnel (e.g., doctor, nurse)
[G] Employee is member of company response team
[H] Student (at school)
[I] 3rd Party Clean-up Contractor
Column "B" (If the victim is a responder) Is the victim a certified HazMat technician?
[1] Yes
[2] No
[3] Not a responder

Column "C"

Severity and disposition of victim
[2] Treated on scene (first aid)
9

[3]
[4]
[5]
[6]
[7]

Treated at hospital (not admitted)
Treated at hospital (admitted)
Observation at hospital; no treatment
Seen by private physician within 24-hours
Injuries experienced within 24 h of event and reported by
official (e.g., fire dep, EMT, police, poison control center)
[8] Treated by mass casualty mobile unit
[A] Death on scene/on arrival at hospital
[B] Death after arrival at hospital
Column "D" Adverse health effects (may be up to seven entries--see training manual
for instructions)
[A] Trauma (drop box to choose whether trauma is chemical-related, not
chemical-related, both or unknown)
[B] Respiratory system problems
[C] Eye irritation
[D] Gastrointestinal problems
[E] Heat stress
[F] Burns (drop box to choose whether burn is chemical-related, not chemicalrelated both, or unknown)
[H] Other _______________(10)
[I] Skin irritation
[J] Dizziness or other CNS symptoms
[L] Headache
[M] Heart problems
[N] Shortness of breath (unknown cause)
Column "E" Personal Protective Equipment (PPE) -- What level of PPE was the victim
using prior to being harmed or killed? (Choose the 1 option that best describes)
[1] None
[2] Level "A"
[3] Level "B"
[4] Level "C"
[5] Level "D"
[6] Fire fighter turn-out gear with respiratory protection
[A] Fire fighter turn-out gear without respiratory protection
[B] Other types of protection (drop down box to select gloves, eye protection,
hard hat,
steel-toed shoes)
Column "F" Sex of victim
[F] Female
[M] Male

Column "G" Age of victim
__ __ __
(Enter numeric age to closest year; if unknown, leave blank and select an age category.
10

If an exact age is entered, the computer will fill in the age category. If age category is
unknown, leave blank.):
[A] less than 12 months old
[B] between 1 and 4 years of age
[C] between 5 and 14 years of age
[D] between 15 and 19 years of age
[E] between 20 and 44 years of age
[F] between 45 and 64 years of age
[G] 65 years of age or more
Column "H" Describe the physical location of the victim at the time harmed in relation
to the point of release
[1] Immediate area where release occurred (e.g., room, railcar, trailer, within 10
feet)
[2] Wing/section of building/11 - 50 feet
[3] Building(s) (may include internal parking areas and roads)/51 - 100 feet
[4] The facility/101 - 200 feet
[5] Between 201 feet - 1/4 mile of point of release
[6] Between 1/4 mile - 2 mile of point of release
[7] Between 2 mile - 1 mile of point of release
[8] Greater than 1 mile of point of release
Column “I” - Decontamination of injured person
[1] No
[2] At the scene
[3] At a medical facility
[4] Both

11

Table I
Victims
Victim
No.

Category

Haz
Mat

Severity

Adverse
health
effect

PPE

Sex

Age

Distance

Decon

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

12

DECONTAMINATION
Record the number of uninjured individuals (by population type) decontaminated at the scene of
the event or at a medical facility. (An individual may be counted in both categories if they were
decontaminated at both locations but count them only once in question 40. If no uninjured
individuals were decontaminated, enter 0 for Q 40; if it is unknown if any uninjured individuals
were decontaminated, leave Q 40 blank.)
40.

Total number of uninjured people decontaminated __ __ __
(If zero or unknown, skip to Q49)

41.

How many uninjured employees were decontaminated at the scene?

__ __ __

42.

How many uninjured responders were decontaminated at the scene?

__ __ __

43.

How many uninjured members of the general population were decontaminated at the
scene? __ __ __

44.

How many uninjured students (at school) were decontaminated at the scene?__ __ __

45.

How many uninjured employees were decontaminated at a medical or other facility?
__ __ __

46.

How many uninjured responders were decontaminated at a medical or other facility?
__ __ __

47.

How many uninjured members of the general population were decontaminated at a
medical or other facility?
__ __ __

48.

How many uninjured students (at school) were decontaminated at a medical or other
facility?
__ __ __

POTENTIAL COMMUNITY EXPOSURE
This section will describe and distinguish between those individuals at risk of being exposed and
those individuals who might actually have been exposed. It will also explore issues related to
evacuation versus in-place sheltering. (If the answer to any question is unknown, leave it blank.)
49.

Approximately how many people live within ¼ mile radius of the event? __ __ __ __

50.

Approximately how many people live within ½ mile radius of the event? __ __ __ __

51.

Approximately how many people live within 1 mile radius of the event? __ __ __ __
(Q52-54 to be computer generated based on formulas but can be overridden by the data
13

entry person if event-specific numbers are known)
52.

Approximately how many people were at home within ¼ mile radius at the time of the
event? __ __ __ __

53.

Approximately how many people were at home within ½ mile radius at the time of the
event? __ __ __ __

54.

Approximately how many people were at home within 1 mile radius at the time of the
event? __ __ __ __

55.

Define the area impacted by the release: (Select only one entry.)
[1] Immediate area where release occurred (e.g., room, railcar, trailer, within 10 feet)
[2] Wing/section of building(11 - 50 feet)
[3] Building(s) (may include internal parking areas and roads)/51 - 100 feet
[4] The facility(101 - 200 feet)
[5] > 201 feet - 1/4 mile of point of release
[6] > 1/4 mile – 1/2 mile of point of release
[7] > 1/2 mile - 1 mile of point of release
[8] Greater than 1 mile of point of release

56.

Was a hospital, ambulance or other patient transport vehicle contaminated as a result of
the event?
1 = Yes
2 = No

57.

Did the event affect any of the following routes of transportation?: (Select all that apply)
[1] Interstate/freeway
[2] Arterial roads
[3] Local roads
[4] Waterway
[5] Railroad/Rail yard
[8] Other _______________ (15)
[A] None

EVACUATION AND IN-PLACE SHELTERING
58.

How many people self-evacuated as a result of the event? __ __ __
(If none, enter 0; if unknown, leave blank).

59.

Did an official order an evacuation? (An official may be the incident commander, a fire
marshal, police officer, plant manager, etc., If unknown, go to question 63.)
14

1 = Yes
2 = No (Go to question 63)
60.

What criteria was used to define the evacuation area?
[1] No defined criteria
[2] Circle/radius
[3] Downwind/downstream
[4] The building(s) or the affected part of the building(s)
[5] Circle and downwind/downstream

61.

Record the total number of people who were officially evacuated as a result of the event.
__ __ __ __ __
(If none enter 0. If any person was evacuated more than one time, count them only once.
If unknown, leave blank and select a category. If category unknown, leave blank If
exact number is entered, the computer will automatically fill in the category.)
1 = less than 5
2 = 5-20
3 = 21-50
4 = 51-100
5=101-500
6=501-1,000
7= greater than 1,000

62.

How many hours was the evacuation order in effect.
__ __ __ __ .__ __ hours
(e.g., if the evacuation lasted two and one-half days, enter 60. If unknown, leave blank.)

63.

Did an official order in-place sheltering? (that is, to stay indoors rather than evacuating)
1 = Yes
2 = No

64.

Was access to the area restricted in any way? (Select all that apply.)
[1] No restriction
[2] Room
[3] Wing/section of building
[4] Building
[5] Facility
[6] Parking lot
[7] Access route/road
[8] Other adjacent areas

RESPONSE TO AND TERMINATION OF EVENT
65.

Were actions taken, excluding decontamination, to stop or control the exposure from the
15

release?
1 = Yes
2 = No

66.

Activities taken to protect public health as a result of this event? (May have ONE or TWO
entries.)
[1] Health advisory issued
[2] Well survey conducted
[3] Alternative water provided
[4] Fishing and/or water recreation ban
[5] Discourage/prohibit consumption of locally grown produce and livestock
[6] Health investigation (epidemiological study, medical monitoring over time,
exposure assessment)
[7] Environmental sampling
[8] Other _______________(15)
[9] Shutdown of water intakes
[10] None

67.

Emergency Action Terminated- Enter the date that the emergency phase of the event
ended according to the incident commander. (MM/DD/YYYY)
__ __ -__ __ -__ __ __ __

68.

Enter the time that the emergency phase of the event ended according to the incident
commander. __ __ : __ __
Use 24-hour time format (e.g., 15:59). If unknown, leave blank and select a time
category. If time category unknown, leave blank. If exact time is entered, the computer
will automatically fill in the time category.)
1 = 00:00 am - 05:59 am
2 = 06:00 am - 11:59 am
3 = 12:00 pm - 05:59 pm/12:00-17:59
4 = 06:00 pm - 11:59 pm/18:00-23:59

69.

Who responded to this incident? (Select all that apply.)
[1] No response
[2] Certified HazMat team
[3] Company=s response team
[4] Law enforcement agency
[5] Fire department
[6] EMS
[7] Hospital personnel/Poison Control Center
[8] Other (Specify __________________)
[A] Health department/health agency
16

[B]
[C]
[D]
[E]
[F]
70.

Environmental agency/EPA response team
3rd Party Clean-up Contractor
Specialized multiagency teams
Department of works/utilities/transportation (includes coast guard)
State, County or local Emergency managers/coordinators/planning committees

Are there any comments on the data collection form?
1 = Yes
2 = No
(If yes, enter the question number and comment in the comments field. For any suggested
questions that were not added to the form, the states can put this info in the comment
field)

71.

Please enter a brief synopsis of the event (200 words or less)

17