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Fields displayed in RED are mandatory entries.  Please fill out the form as completely as possible. 
IS THIS A DRILL REPORT ? YES  NO    YOUR E-MAIL ADDRESS: 

REPORTING PARTY

SUSPECTED RESPONSIBLE PARTY
Phone 1:       Type: Last Name: 
Last Name:  First Name: 
First Name:  Phone 1:        Type:
Phone 2:       Type: Phone 2:        Type:
Phone 3:       Type: Phone 3:        Type:
Company:     Company:     
Org Type:    Org Type:    
Address:      Address:      
                                            
City:             City:             
State:           State:           
ZIP:              ZIP:              
Does the caller wish to remain Confidential ?  Yes  No
Are you calling on behalf of responsible party ? Yes  No
Are you or your company responsible for the Material released ?   Yes  No

INCIDENT DESCRIPTION
Description of Incident: 
 
Incident Date: 
                             (DD/MM/YY)     		 Time:    Occurred/Discovered/Planned: 
Type of Incident:  FIXED Incident Cause: 

ACCIDENT LOCATION
Location Description:
Address Location:
  		State:     

County:   

ZIP:       

Nearest City:            Distance from City:               Units:
Direction:            Range:    Section:    Township: 
Latitude -     Degrees:    Minutes:  Seconds:      Quadrant: 
Longitude -  Degrees:   Minutes:    Seconds:      Quadrant: 

FIXED INCIDENT LOCATION DETAILS
Building ID: 

FIXED INCIDENT  DESCRIPTION DETAILS
Fixed Object / Facility Type:    
Compliance with NPDES Permits ?  Yes  No  Unknown
Power Generating Facility ?  Yes  No  Unknown    

MATERIAL INVOLVED

Material

CHRIS CODE

Amount Released

Units
MATERIAL IN WATER INFORMATION

Amount in Water:  Units:

Body of Water Affected:

Offshore:  Yes  No

River Mile Marker:

Tributary of:

Water Supply Contaminated:  Yes   No  Unknown    Water Temperature:   Units: 

Wave Condition: Speed:    Units:   Direction:

SHEEN INFORMATION

Sheen Length:    Units:      Sheen Width:    Units:

Color: 

Direction of Movement: 

Odor Description: 

 
IMPACT INFORMATION

Medium Affected:          Detailed Medium Information:

Fire ?

 Yes  No  Unknown Fire Extinguished ?          Yes  No  Unknown
Injuries ? Yes  No  Unknown Number of Injuries ?       
Fatalities ? Yes  No  Unknown Number of Fatalities ?     
Evacuations ? Yes  No  Unknown Number of Evacuations ?
Damages ? Yes  No  Unknown Damage in Dollars:           
Road Closed ? Yes  No  Unknown Road:                                   
Track Closed ? Yes  No  Unknown Track:                                 
Air Corridor Closed ? Yes  No  Unknown Air Corridor:                    
Waterway Closed ? Yes  No  Unknown Waterway:                         
Community Impact Due to Material     Yes  No  Media Interest:          

WEATHER INFORMATION

Weather Conditions:  Air Temperature:   
Wind Speed:    Unit:  Wind Direction: 

REMEDIAL ACTION INFORMATION

Remedial Action Taken:  
Release Secured ?   Yes  No  Unknown       Duration of Release ?    Unit: 
Rate of Release ?        Unit:    Per: 

ADDITIONAL AGENCY INFORMATION

Federal Agency Notified: 
State/Local Agency Notified: 
State/Local Agency On-Scene: 
State Agency's Report Number: 

ADDITIONAL INFORMATION

 

 

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