Instructions Revised 2021.02.11 Justification

Expiration Date: xx- xx-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 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 omaterials in process and released prior to and after the incident. and quantity of ,re, temperatureInclude equipment pressu. releasef accidental
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. Property Damage	Mark “Yes” if the accidental release resulted in damage to facility property (equipment, buildings, piping, storage tanks etc.); otherwise, mark “No.”
g. Name of the materials involved in accidental release using the Chemical Abstract Service (CAS) ).Add more lines if more than two chemicals(. number(s) or other appropriate identifiersregistry	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. Amount 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.
h1. Quantity Released	Provide the amount of the chemical released during the accidental release.
h2. Quantity Released	Provide the amount of the chemical released during the accidental release.
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? .”“Yes” or “NoMark	Provide information on any evacuation order issued as a result of the accidental release. , mark “No.”; otherwiseevacuation order nin aresulted accidental release Mark “Yes” if the
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.

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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