Hazmat Incident Reporting Form

Hazardous Materials
Incident Report

U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration

Form Approval OMB No. 2137-0039

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 2137-0039. The filling out of this information is
mandatory and will take 96 minutes to complete .
INSTRUCTIONS: Submit this report to the Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials
Safety Administration, Offi ce of Hazardous Materials Safety, DHM-63, Washington, D.C. 20590-0001. If space provided for any item is inadequate,
use a seperate sheet of paper, identifying the entry number being completed. Copies of this form and instructions can be obtained from the Offi ce
of Hazardous Materials Website at http://hazmat.dot.gov. If you have any questions, you can contact the Hazardous Materials Information Center at
1-800-HMR-4922 (1-800-467-4922) or online at http://hazmat.dot.gov.

PART I - REPORT TYPE
1. This is to report:

A) hazardous material incident

B) An undeclared shipment with no release

C) A specification cargo tank 1,000 gallons or greater containing any hazardous materials that
(1) received structural damage to the lading retention system or damage that requires repair to a system
intended to protect the lading retention system and (2) did not have a release.

2. Indicate whether this is:

An initial report

Additional Pages

A supplemental (follow-up) report

PART II - GENERAL INCIDENT INFORMATION
4. Time of Incident (use 24-hour time):

3. Date of Incident:
5. Enter National Response Center Report Number (if applicable):

6. If you submitted a report to another Federal DOT agency, enter the agency and report number:
7. Location of Incident:

City:

ZIP Code (if known):

State:

County:

Street Address/Mile Marker/Yardname/Airport/Body of Water/River Mile
8. Mode of Transportation

Air

Highway

Rail

Water

9. Transportation Phase

In Transit

Loading

Unloading

In Transit Storage

10. Carrier/Reporter

Name
Street
City
Federal DOT ID Number

11. Shipper/Offeror

ZIP Code

State
Hazmat Registration Number

Name
Street
State

City

Hazmat Registration Number

Waybill/Shipping Paper
12. Origin

(if different from
shipper address)

13. Destination

ZIP Code

Street
City

State

ZIP Code

State

ZIP Code

Street
City

14. Proper Shipping Name of Hazardous Material:
15. Technical/Trade Name:
16. Hazardous Class/
Division:

17. Identification
Number:

18. Packing
Group:

(E.g. UN2764, NA2020)

19. Quantity
Released:
(Include Measurement Unit)

(if applicable)

20. Was the material shipped as a hazardous waste?

Yes

No

If yes, provide the EPA Manifest Number:

21. Is this a Toxic by Inhalation (TIH) material?

Yes

No

If yes, provide the Hazard Zone:

22. Was the material shipped under an Exemption, Approval, or Competent Authority Certificate?

Yes

No

Yes

No

If yes, provide the Exemption, Approval, or CA number:
23. Was this an undeclared hazardous materials shipment?
Form DOT F 5800.1 (01-2004)

Page 1

Reproduction of this form is permitted

PART III - PACKAGING INFORMATION
24. Check Packaging Type (check only one - if more than one, list type of packaging, copy Part III, and complete for each type:
Non-bulk

Portable Tank

Cargo tank Motor Vehicle (CTMV)

Tank Car

Cylinder

Radioactive Material
(RAM)

Intermediate Bulk Container (IBC)

Other

25. See instructions and enter the appropriate failure codes found at the end of the instructions. Be sure to enter the codes from the list
that corresponds to the particular packaigng type checked above. Enter the number of codes as appropriate to describe the incident.
Enter the most important failure point in line 1. If there are more than two failures, provide in this format in part VI.
1. What Failed:

How Failed:

Causes of Failure:

2. What Failed:

How Failed:

Causes of Failure:

26a. Provide the packaging identifi cation markings, if available.
Identification Markings:
(Examples: 1A1/Y1.4/150/92/USA/RB/93/RL, UN31H1/Y0493/USA/M9339/10800/1200, DOT - 105A - 100W (RAIL), DOT 406 (HIGHWAY), DOT 51, DOT 3-A)

26b. For Non-bulk, IBC, or non-specification packaging, if identification markings are incomplete or unavailable, see instructions and
complete the following:
Single Package or Outer Packaging:

Single Package or Inner Packaging (if any):

Packaging Type:

Packaging Type:

Material of Construction:

Material of Construction:

Head Type (Drums Only):

Removable

Non-Removable

27. Describe the package capacity and the quantity:
Single Package or Outer Packaging:

Single Package or Outer Packaging:

Package Capacity:

Package Capacity:

Amount in Package:

Amount in Package:

Number in Shipment:

Number in Shipment:

Number Failed:

Number Failed:

28. Provide packaging construction and test information, as appropriate:
Manufacturer:

Manufacture Date:

Serial Number:

Last Test Date:

Material of Construction:

(if Tank Car, CTMV, Portable Tank, or Cylinder)

Design Pressure:

(if Tank Car, CTMV, Portable Tank)

Shell Thickness:

(if Tank Car, CTMV, Portable Tank)

Head Thickness:

(if Tank Car, CTMV)

Service Pressure:

(if Cylinder)

If valve or device failed:
Type:

Model:

Manufacturer:
(if present and legible)

(if present and legible)

29. If the packaging is for Radioactive Materials, complete the following:
Packaging Category:

Type A

Type B

Packaging Certification:

Self Certified

U.S. Certification

Type C

Nuclide(s) Present:

Transport Index:

Activity:

Critical Safety Index:

Form DOT F 5800.1 (01-2004)

Page 2

Excepted

Industrial

Certification Number

Reproduction of this form is permitted

PART IV - CONSEQUENCES
30. Result of Incident (check all that apply):

Spillage

Explosion

Fire

Environmental Damage

Vapor (Gas) Dispersion
31. Emergency Response :

The following entities responded to the incident:

Fire/EMS Report #
32. Damages:

Police Report #

If yes, enter the following information:

In-house cleanup
Yes

Other Cleanup

No

If no, go to question 33.

Carrier Damage:

Property Damage:

$

$

No Release

(Check all that apply)

Was the total damage cost more than $500?

Material Loss:

Material Entered Waterway/Storm Sewer

$

Response Cost:

Remediation/Cleanup Cost:

$

$

(See damage defi nitions in the instructions)

Yes

33a. Did the hazardous material cause or contribute to a human fatality?

No

If yes, enter the number of fatalitiies resulting from the hazardous material:
Fatalities:

Responders

Employees

General Public

33b. Were there human fatalities that did not result from the hazardous material?

Yes

No

34. Did the hazardous material cause or contribute to personal injury?

Yes

No

If yes, how many?

If yes, enter the number of injuries resulting from the hazardous material:
Hospitalized (Admitted Only):

Employees

Responders

General Public

Non-Hospitalized:

Employees

Responders

General Public

(e.g.: On site fi rst aid or Emergency Room observation and release)

35. Did the hazardous material cause or contribute to an evacuation?

Yes

No

If yes, provide estimates for the following information:
Total number of employees evacuated

Total number of general public evacuated
Duration of the evacuation

Total Evacuated

(hours)

36. Was a major transportation artery or facility closed?

Yes

No

37. Was the material involved in a crash or derailment?

Yes

No

If yes, provide the following information:

Estimated speed (mph):

(hours)

Weather conditions:

Vehicle overturn?

Yes

No

Vehicle left rodway/track?

Yes

No

PART V - AIR INCIDENT INFORMATION

If yes, how many?

(please refer to § 175.31 to report a discrepancy for air shipments)

38. Was the shipment on a passenger aircraft?

Yes

No

If yes, was it tendered as cargo, or as passenger baggage?
Cargo

Passenger baggage

39. Where did the incident occur (if unknown, check the appropriate box for the location where the incident was discovered)?
Air carrier cargo facility

Sort center

Baggage area

By surface to/from airport

During flight

During loading/unloading of aircraft

40. What phase(s) had the shipment already undergone prior to the incident? (Check all that apply)
Shipment had not been transported

Transported by air (first flight)

Initial transport by highway to cargo facility

Transfer at sort center/cargo facility

Form DOT F 5800.1 (01-2004)

Page 3

Transport by air (subsequent fl ights)

Reproduction of this form is permitted

PART VI - DESCRIPTION OF EVENTS & PACKAGE FAILURE
Describe the sequence of events that led to the incident and the actions taken at the time it was discovered. Describe the package failure, including
the size and location of holes, cracks, etc. Photographs and diagrams should be submitted if needed for clarifi cation. Estimate the duration of the
release, if possible. Describe what was done to mitigate the effects of the release. Continue on additional sheets if necessary.

PART VII - RECOMMENDATIONS/ACTIONS TAKEN TO PREVENT RECURRENCE
Where you are able to do so, suggest or describe changes (such as additional training, use of better packaging, or improved operating
procedures) to help prevent recurrence. Provide recommendations for improvement to hazardous materials transportation beyond the control of
your individual company. Continue on additional sheets if necessary.

PART VIII- CONTACT INFORMATION
Contact’s Name (Type or Print):

Telephone Number: (

Contact’s Title:

Fax Number: (

Business Name and Address:

Hazmat Registration Number (if not already provided):

E-mail Address:

Date:

Preparer is:

Carrier

Form DOT F 5800.1 (01-2004)

Shipper

Facility
Page 4

SUBMIT

)

)

Other
Reproduction of this form is permitted