OMB No. 3301-0001 CSB Accidental Release Reporting Form

Expiration Date: 04-30-2023

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:

c4. Zip Code:

d1. Time of Accidental Release:

d2. Date of Accidental Release:

e. Describe the accidental release:

6. 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:	Yes	No
f2. Fire:	Yes	No
f3. Death:	Yes	No
f4. Serious Injury:	Yes	No
f5. Substantial Property Damage:	Yes	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:

g2. CAS Name and Number:

h. Quantity of chemical(s) involved in the accidental release, if known. List chemical name and quantity released. (Use additional page(s) if necessary.)

1. Number of Fatalities:

10. Number of Serious Injuries:

10. Estimated Property Damage:

10. 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

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 four ways:

1. Contact the CSB by telephone at 202-261-7600 and provide the required information 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, contact the CSB by telephone at 202-261-7600 and provide the NRC report identification number. You are not required to submit the CSB reporting form, but the NRC report itself does need to provide the required information.

4. 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, but the NRC report itself does need to provide the required information.

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 e- mail 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	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 title of the facility contact.
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. E-mail	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.
e. Describe 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.
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	Indicate the following consequences that best describes the impact of the accidental release and mark all that apply.
f1. Explosion	Mark “Yes” if the accidental release resulted in an explosion; otherwise, mark “No.”
f2. Fire	Mark “Yes” if the accidental release resulted in a fire; otherwise, mark “No.”
f3. Death	Mark “Yes” if the accidental release resulted in a death (fatality); otherwise, mark “No.”
f4. Serious Injury	Mark “Yes” if the accidental release resulted in a serious injury (inpatient hospitalization); otherwise, mark “No.”

f5. Substantial Property Damage	Mark “Yes” if the accidental release resulted in estimated damage to property at or outside the stationary source equal to or greater than $1,000,000.; otherwise, mark “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).	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.
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. Quantity of chemical(s) involved in the accidental release, if known. List chemical name and quantity released (use additional page(s) if necessary).	Provide the quantity of all chemicals released in the form of a list.
i. 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).
j. 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	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? Mark “Yes” or “No.”	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.”
l1. Number of People Evacuated	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). Mark all that apply.	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	Signature of the person filling out the form.
Print Name	Print the first and last name of the person filling out the form.

Paperwork Reduction Act Statement.

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

Confidentiality and Disclosure Statement

The disclosure of any information collected on this form is subject to the Freedom of Information Act (FOIA) (5 U.S.C. 552) and 40 CFR Part 1601, the CSB’s procedures for the disclosure of records under the FOIA. Accidental release records collected by the CSB may be obtained by making a request in accordance with 40 CFR Part 1601. The CSB will process and, if appropriate, disclose such records, in accordance with 40 CFR Part 1601 and relevant federal information disclosure laws. The CSB also continues to proactively disclose limited information on a quarterly basis on its website at https://www.csb.gov/news/incident-report-rule-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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