Report Form and Instructions

Expiration Date: xx-xx-23

OMB No. 3301-0001

CSB Accidental Release Reporting Form

a1. Name of Owner/Operator: a2. Name of Owner/Operator Contact:

a3. Title of Owner/Operator 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. Email:

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. 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 occurred during the accidental release.

Circle all that apply, to the extent known:

f1. Explosion: Yes No
f2. Fire: Yes No
f3. Death: Yes No
f4. Serious Injury Yes No
f5. Property damage Yes No

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

g1. Name CAS:

g2. Name CAS:

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.

h1. Quantity released: _______________________________________________________________

h2. Quantity released: _______________________________________________________________

i1. Number of Fatalities:

j2. Number of Serious Injury(ies):

k. Estimated property damage at or outside stationary source.

l. If known, did the accidental release result in an evacuation order to members of the general public or others?

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). Circle all that apply.

Employees evacuated Yes No

General public evacuated Yes No

Signature:
Date

Print Name: First name Last name

2