Form OMB No. 3301-0001 OMB No. 3301-0001 CSB Accidental Release Form

Expiration Date: 04-30-23
OMB No. 3301-0001
CSB Accidental Release Reporting Form
a1. Owner/Operator:

a2. Name of Owner/Operator Contact:

a3. Title of Facility Contact:

a4. Mobile Phone Number:

a5. E-mail Address:

a6. Office Phone Number:

b1. Name of Person Submitting Report:
b2. Title:
b3. Mobile Phone Number:

b4. Office Phone Number:

b5. E-mail:
c1. Facility Name:
c2. Facility Street Address:

c3. City:

d1. Time of Accidental Release:

c4. Zip Code:

d2. Date of Accidental Release:

e. Describe the accidental release:
f. Indicate if one or more of the following consequences occurred during the accidental release.
Mark all that apply, to the extent known at the time of the incident.
f1. Explosion:
f2. Fire:
f3. Death:
f4. Serious Injury:
f5. Property Damage:

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

g: Name of the materials involved in accidental release using the Chemical Abstract Service
(CAS) registry number(s) or other appropriate identifiers. (Add more lines if more than two
chemicals.)
g1. CAS Name and Number:

1

Expiration Date: 04-30-23
OMB No. 3301-0001
g2. CAS Name and Number:

h. Amount of chemical(s) involved in the accidental release, if known. List chemical name and
quantity released. (Use additional page(s) if necessary.)
h1. Quantity Released:
_______________________________________________________________
h2. Quantity Released:
_______________________________________________________________
i. Number of Fatalities:

j. Number of Serious Injuries:
k. Estimated Property Damage:

l. If known, did the accidental release result in an evacuation order to members of the general
public or others? Mark “Yes” or “No.”
Evacuation Order:

Yes

No

l1. Number of People Evacuated:
l2. Approximate Radius of Evacuation Zone:
l3. Type of individuals subject to evacuation order (i.e., employees, members of the general
public, or both). Mark all that apply.
Employees Evacuated:

Yes

No

General Public Evacuated:

Yes

No

Signature:
Date
Print Name:

First name

Last name
2