Hazardous Materials Incidents Page 2
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2DESCRIBE WHAT HAPPENED:____________________________________________________________________________
______________________________________________________________________________________________________
_______________________________________________________________________________________________________
WIND DIRECTION FROM:_________________ WIND SPEED:______________MPH (0-5, 6-10, 11-15, etc)
WEATHER TYPE:
CLEAR
SUNNY
PARTLY CLOUDY
CLOUDY
DRIZZLE
LIGHT RAIN
RAIN
FOG
SNOW
SLEET
OTHER:__________________________
RESIDENTS WITHIN ¼ MILE:
NO
YES, APPROXIMATE NUMBER:__________________________________________
PERSONAL INJURIES:
NO
YES, NUMBER:_________
FATALITIES:
NO
YES, NUMBER:_______________
EMERGENCY CREWS ON SCENE:
FIRE
AMBULANCE
LAW ENFORCEMENT
EMERGENCY MGMT
KS FIRE MARSHALL REGIONAL RESPONSE TEAM
OTHER:____________________________
IS THE INCIDENT AREA SECURED:
YES
NO
NAME OF CHEMICAL/COMMODITY:_________________________________________________________________________
NAME OF PLACARD (UN NUMBER):_________________________________ CAS NUMBER:__________________________
CARRIER NAME:____________________________ TRUCK/TRAIN #:______________ TRAILER/RAILCAR #:_____________
QUANTITY RELEASED:________ QTY. IN WATER:__________ CONTAINER CAPACITY:__________ UNITS:____________
PHYSICAL FORM (CHECK ALL THAT APPLY):
LIQUID
SOLID
GAS
MEDIUM AFFECTED (CHECK ALL THAT APPLY):
AIR
SOIL
WATER
GROUNDWATER
NONE
WITHIN FACILITY
OTHER:_________________________
IF RELEASED TO WATER: TYPE OF WATERWAY:_____________________ NAME:_________________________________
ACTIONS TAKEN TO REMEDIATE THE INCIDENT: _____________________________________________________________
________________________________________________________________________________________________________
DID EVACUATIONS OCCUR:
NO
YES, NUMBER EVACUATED: FACILITY:_____________
PUBLIC:_______________
DID SHELTER IN PLACE OCCUR:
NO
YES, NUMBER SHELTERED IN PLACE:_______________________________
BOUNDARIES OF EVACUATION OR SHELTER IN PLACE AREA:__________________________________________________
________________________________________________________________________________________________________
OTHER PROTECTIVE ACTIONS RECOMMENDED:_____________________________________________________________
________________________________________________________________________________________________________
KNOWN OR ANTICIPATED ACUTE HEALTH RISKS:
NO
YES _____________________________________________
KNOWN OR ANTICIPATED CHRONIC HEALTH RISKS:
NO
YES ___________________________________________
IDENTIFY MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS:_______________________________________
________________________________________________________________________________________________________
Page 2 of 2
REVISED 10/13
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