Hazardous Materials Incidents

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FORM A
Hazardous Materials Incidents / Accidents / Continuous Releases
REPORT INCIDENT IMMEDIATELY to the KANSAS DIVISION OF EMERGENCY MANAGEMENT (KDEM)
Telephone: (785) 296-3176 or (800) 905-7521
THIS COMPLETED FORM must be submitted on-line or faxed to KDEM (785) 274-1426, Technological Hazards
Section, AS SOON AS PRACTICABLE (not to exceed 7 days) after the verbal notification.
Form A(s) may be used as
the written follow-up notification to KDEM ONLY IF an UPDATED Form A is submitted after the incident has concluded
and includes additional information on the cause of the release, information on actual response actions taken,
identification of any acute or chronic health risks and advice regarding medical attention necessary for citizens exposed,
if appropriate. Additional information can be mailed to KDEM at: 2800 SW Topeka Blvd, Topeka, KS 66611.
 The following fields may have multiple entries: Commodity, Physical Form, Incident Mode, Truck/Trailer Number,
Railcar Number, and Placard. If there is not enough room on this form to report these fields or “What Happened” or
“Actions Taken to Remediate the Incident” please attach another page with the additional details.
KDEM CONFIRMATION NUMBER:_____________________________________
WAS A REPORT MADE TO THE FOLLOWING AGENCIES:
LOCAL EMERGENCY PLANNING COMMITTEE……………….……..…
YES
YES CASE#_______________________________
NATIONAL RESPONSE CENTER (800) 424-8802……………………….
YES CASE#_______________________________
KANSAS DEPT. OF HEALTH & ENVIRONMENT (785) 296-1679..…….
SPILLER INFORMATION:
IS THIS AN UPDATE TO FORM A:
YES
DOES THIS CONSTITUTE A CONTINUOUS RELEASE:
YES
IF CONTINUOUS, CR-ERNS #:____________________
PERSON INITIATING THE CALL:___________________________________________________________________________
CALLER ORGANIZATION:________________________________________________________________________________
CALLER PHONE:____________________________
CALLER EMAIL:_______________________________________
ARE YOU THE SPILLER:
YES
NO
IF NO, SPILLER ORGANIZATION:___________________________________
SPILLER ORGANIZATION ADDRESS:______________________________________________________________________
CITY:_____________________________ STATE:_______ COUNTY:______________________ ZIP:__________________
SPILLER PHONE:________________________
SPILLER EMAIL:_______________________________________________
INCIDENT INFORMATION:
DISCOVERY TIME:______________________________ DISCOVERY DATE:______________________________________
NOTIFICATION TIME:____________________________ NOTIFICATION DATE:____________________________________
INCIDENT LOCATION/ADDRESS:__________________________________________________________________________
INCIDENT CITY:_________________________________ INCIDENT COUNTY:_____________________________________
MANUFACTURER/SHIPPER:______________________________________________________________________________
CAUSE OF RELEASE:
EXPLOSION
SPILL
OPERATOR ERROR
NATURAL PHENONENA
FIRE
DUMPING
EQUIPMENT FAILURE
OTHER*
*IF OTHER, DESCRIBE:__________________________________________________________________________________
INCIDENT MODE:
AIRCRAFT
FIXED FACILITY
MOTOR CARRIER
MOTOR VECHICLE
PIPELINE
RAIL
OTHER (DESCRIBE):__________________________________________________________________________________
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REVISED 10/13

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