CSB Accidental Release Form

Expiration Date: 04-30-2023
OMB No.: 3301-0001
General Instructions for Completing CSB Accidental Release Form
You are required to report an accidental release within eight hours of a qualifying event. See 40
C.F.R. Part 1604. You may report an accidental release pursuant to 40 C.F.R. § 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; or
2. Fill out and submit this form with appropriate response to the CSB by e-mail to
[email protected]; or
3. If you have submitted a report to the National Response Center (NRC) for the same
incident under CERCLA, 40 C.F.R. § 302.6, e-mail 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 and Hazard Investigation
Board, 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
a1. Owner/Operator

Instructions
Provide the name of the owner or operator of the facility.

a2. Name of
Owner/Operator Contact
a3. Title of Facility Contact

Name of the point of contact for the facility reporting the
incident.
Provide the title of the facility contact.

a4. Mobile Phone Number

Provide the mobile phone number of the point of contact.

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Expiration Date: 04-30-2023
OMB No.: 3301-0001
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
c4. Zip Code
d1. Time of Accidental
Release
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

Provide the e-mail address for the point of contact for the
facility.
Provide the office phone number for the point of contact for
the facility.
Name of person submitting the report.
Provide the title of the person submitting the report.
Provide the mobile phone number of the person submitting
the report.
Provide the office phone number for the person submitting
the report.
Provide the e-mail address for the person submitting the
report.
Provide the name of the facility.
Provide the address of the facility.
Provide the city where the accidental release occurred.
Provide the zip code of the facility reporting the accidental
release.
Provide the time of the accidental release.
Provide the date of the accidental release.
Description of accidental release. Include equipment
pressure, temperature, and quantity of materials in process
and released prior to and after the incident.
Indicate the following consequences that best describes the
impact of the accidental release and mark all that apply.

Mark “Yes” if the accidental release resulted in an explosion;
otherwise, mark “No.”
Mark “Yes” if the accidental release resulted in a fire;
otherwise, mark “No.”
Mark “Yes” if the accidental release resulted in a death
(fatality); otherwise, mark “No.”
Mark “Yes” if the accidental release resulted in a serious
injury (inpatient hospitalization); otherwise, mark “No.”
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Expiration Date: 04-30-2023
OMB No.: 3301-0001
f5. Property Damage

Mark “Yes” if the accidental release resulted in damage to
facility property (equipment, buildings, piping, storage tanks
etc.); otherwise, mark “No.”
Provide the Chemical Abstracts Service (CAS) name and
registry number, 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.

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 Enter CAS or other chemical identifier name and number.
g2. CAS Name and Number

Enter CAS or other chemical identifier 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

Provide the quantity of all chemicals released in the form of
a list.

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.”
l1. Number of People
Evacuated

Provide the amount of the chemical released during the
accidental release.
Provide the amount of the chemical released during the
accidental release.
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).
Provide a count of the employees, contract workers, or
members of the public seriously injured from the accidental
release.
Provide information on property damage on site and/or
outside the fence line of the stationary source.
Provide information on any evacuation order issued as a
result of the accidental release. Mark “Yes” if the accidental
release resulted in an evacuation order; otherwise, mark
“No.”
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.
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OMB No.: 3301-0001
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.
Signature
Print Name

Provide information on the approximate radius of the
evacuation zone (i.e., 1 mile), if known at the time this report
is issued.
Provide information on the type of individuals subject to the
evacuation order. Mark all that apply. (Mark “Yes” if
employees were evacuated; otherwise, mark “No.” Mark
“Yes” if members of the general public were evacuated;
otherwise, mark “No.” If both employees and the general
public were evacuated, mark “Yes” for each.)
Signature of the person filling out the form.
Print the first and last 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. Part 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) near 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 Chemical
Safety and Hazard Investigation Board, 1750 Pennsylvania Ave., NW, Suite 910, Washington,
DC 20006.

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