NRC Online Reporting - Railroad Report

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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: RAILROAD	Incident Cause:
ACCIDENT LOCATION
Location Description:
Address Location:		State: County: ZIP:
Nearest City: Distance from Nearest City: Units:
Direction: Range: Section: Township:
Latitude: Degrees: Minutes: Seconds: Quadrant:
Longitude: Degrees: Minutes: Seconds: Quadrant:
RAILROAD DETAILS
Brake Failure Incident ?: Yes No		Subdivision: Mile Post:
If Transit Service was interrupted, Date/Time service will be restored:
GRADE CROSSING DETAILS
Grade Crossing Incident ? Yes No		Type of Vehicle Involved:
Crossing Device:		Device Operational ? Yes No
DOT Crossing Number:		Allision ? Yes No
TRAIN DETAILS
Railroad Name: Train Type: Unit Number:
Number of Locomotives: Number of Cars: Number of Derailed:
Train Speed: Track Speed: Train Direction:

Railroad Name: Train Type: Unit Number:
Number of Locomotives: Number of Cars: Number of Derailed:
Train Speed: Track Speed: Train Direction:

Suspected Non-Compliance with DOT Regulations ?: Yes No
DERAILED DETAILS
Car Number: Position: Car Locomotive Cargo/Contents:
Car Number: Position: Car Locomotive Cargo/Contents:
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 Release Duration ? 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
Additional Information:

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