CSB Accidental Release Form

Expiration Date: xx- xx-2023

OMB No.: 3301-0001

General Instructions for completing CSB Accidental Release Form

You are required to report an accidental release within four hours of a qualifying event. See 40 C.F.R. 1604. You may report an accidental release pursuant to 40 C.F.R. Part 1604.3 in one of three ways:

1. Contact the CSB by telephone at 202-261-7600 and answer a series of questions based on the attached form;

2. Fill out and submit this form with appropriate response to the CSB by email to [email protected]; or

3. If you have submitted a report to the National Response Center for the same incident under CERCLA, 40 CFR 302.6, email the CSB with the NRC report identification number at [email protected]. You are not required to submit the CSB reporting form.

An owner or operator of a stationary source, without incurring a penalty, may revise and/or update information reported to the NRC or CSB by sending a notification with revisions by email to: [email protected], or by correspondence to: Chemical Safety Board (CSB) 1750 Pennsylvania Ave., NW, Suite 910, Washington, DC 20006, within 30 days following the submission of a report to the NRC or CSB. If applicable, please include the original NRC identification number. Please do not send updates or revisions to the notification to the NRC, even in instances when NRC issued an identification number.

Specific Instructions

Form Item	Instructions
a1. Owner/Operator	Provide the name of the owner or operator of the facility.
a2. Name of Owner/Operator Contact	Name of the point of contact for the facility reporting the incident.
a3. Title of Facility Contact	Provide the facility title.
a4. Mobile Phone Number	Provide the mobile phone number of the point of contact.
a5. E-mail address	Provide the e-mail address for the point of contact for the facility.
a6. Office Phone Number	Provide the office phone number for the point of contact for the facility.
b1. Name of Person Submitting Report	Name of person submitting the report.
b2. Title	Provide the title of the person submitting the report.
b3. Mobile Phone Number	Provide the mobile phone number of the person submitting the report.
b4. Office Phone Number	Provide the office phone number for the person submitting the report.
b5. Email	Provide the e-mail address for the person submitting the report.
c1. Facility Name	Provide the name of the facility.
c2. Facility Street Address	Provide the address of the facility.
c3. City	Provide the city where the accidental release occurred.
c4. Zip Code	Provide the zip code of the facility reporting the accidental release.
d1. Time of Accidental Release	Provide the time of the accidental release.
d2. Date of Accidental Release	Provide the date of the accidental release.
f. Indicate if one or more of the following consequences occurred during the accidental release, and circle all that apply, to the extent known at the time of the incident	Indicate the following consequences that best describes the impact of your accidental release and check all that apply.
f1. Fire	A fire is the combustion of flammable materials producing light, flames, and heat.
f2. Explosion or deflagration	An explosion is a rapid chemical reaction with the production of noise, heat, and violent expansion of gases, whether supersonic (explosion) or subsonic (deflagration).
f3. Death	Any fatality resulting from the accidental release.
f4. Serious Injury	Any in-patient hospitalization resulting from the accidental release (OSHA 1904 subpart E).
f5. Property damage	Mark “Yes” if the accidental release resulted in damage to facility property (equipment, buildings, piping, storage tanks etc.,); otherwise, mark “No”
g. List All Chemicals Released	Provide the Chemical Abstracts Service (CAS) name and number or International Union of Pure and Applied Chemistry, IUPAC name and number or other appropriate chemical identifier name and number of all chemicals released during the accidental release.
g1. Name CAS	Enter CAS or other chemical identifier name and number.
g2. Name CAS	Enter CAS or other chemical identifier name and number.
h. Amount of chemical(s) named in g, released during the accidental release, if known – list chemical name and quantity released (use additional paper if necessary)	Provide the quantity of all chemicals released in the form of a list.
h1. Quantity Released	Provide the amount of the chemical released during the accidental release.
h2. Quantity Released	Provide the amount of the chemical released during the accidental release.
i1. Number of Fatalities	Provide a count of the employees, contract workers or members of the public fatally injured from the accidental release (clearly distinguish the impact on each group).
j1. Number of Serious Injuries	Provide a count of the employees, contract workers or members of the public seriously injured from the accidental release.
k. Estimated property damage at or outside the stationary source	Provide information on property damage on site and/or outside the fence line of the stationary source.
l. If known, did the accidental release result in an evacuation order to members of the general public or others?	Provide information on any evacuation order issued as a result of the accidental release.
l1. Evacuation	Indicate the number of employees and/or members of the general public evacuated due to the accidental release, if known at the time this report is issued.
l2. Approximate radius of evacuation zone	Provide information on the approximate radius of the evacuation zone (i.e., 1 mile), if known at the time this report is issued
l3. Type of individuals subject to evacuation order (i.e., employees, members of the general public, or both). Circle all that apply.	Provide information on the type of individuals subject to the evacuation order. Circle all that apply. (If only employees were affected, only circle “Yes.” If both employees and the general public were evacuated, circle “Yes” for each.
Signature	Provide the signature of the person filling out the form.
Print Name	Print the name of the person filling out the form.
Last name	Provide the last name of the person filling out the form.
First name	Provide the first name of the person filling out the form.

Public Burden Information

This collection of information is estimated to take an average of fifteen minutes per response, including time for reviewing the instructions, gathering the data needed, and completing the form. This is a mandatory collection under 40 C.F.R. § 1604.

Pursuant to the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to respond to, a collection of information unless it displays a currently valid OMB control number (OMB 3301-0001), is displayed here and in the upper right-hand corner of the first page of this CSB Form 2020-1. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the General Counsel, Chemical Safety and Hazard Investigation Board, Suite 910, 1750 Pennsylvania Ave., NW. Washington, DC, 20006.

6