ND Department of Emergency Services: Haz-Chem Preparedness and Response : Online Form

nd.gov - The Official Portal for North Dakota State Government

Operations and Planning

Operations

Planning

Haz-Chem Preparedness and Response

Report an Incident

WebEOC

Fire Danger Awareness

Disaster Recovery and Mitigation

Homeland Security Program

Training and Exercise

Training and Events Calendar

Get Ready, Get Set, Get Safe

County/Tribal Emergency Management

Donations

Home

Online Form

Hazardous Materials Incident Follow-Up Report (All Fields are Required)

State Incident Number:

Date of This Report:

Name of Facility:

Location of Incident:

Contact Person:

Work Telephone Number:

Home Telephone Number:

Address:

City:

State:

Zip Code:

Incident Date:

Incident Time:

Notification Date:

Notification Time:

Was the incident reported to the
National Response Center?:

Yes
No

Person Submitting This Report:

Phone:

Email:

Substance Identity

Trade Name:

Chemical Name:

CAS Name:

Is this substance on the
EXTREMELY HAZARDOUS SUBSTANCE (EHS) list?:

Yes
No
Do Not Know

Type of Incident:

01 Passenger Road Transportation	06 Heavy Industrial and Agricultural Equipment
02 Freight Road Transport Vehicle	07 Special Transport Vehicle
03 Rail Transport Vehicle	08 Pipeline
04 Water Transport Vehichle	09 Other Transportation Types
05 Air Transport Vehicle	10 Fixed Facility

Type of Release:

01 Spill	03 Explossion	05 Other (Explain)
02 Fire	04 Equipment Failure	06 Other

Extent of Release:

00 Extent Undetermined	05 Confined to fixed property of Orgin
01 Confined to Equipment/Vechile of Orgin	06 Confined to General Property of Orgin
02 Confined to Room of Orgin	07 Released Beyond Property of Orgin
03 Confined to Floor of Orgin	08 No Release
04 Confined to Structure of Orgin	09 Extent of Release Not Classified Above

Meduim Affected by This Release (air/water/soil):

00 Medium Undetermined	05 Air and Ground
01 Air	06 Water and Air
02 Water	07 Air, Water, and Ground
03 Ground	08 Not Released
04 Water and Ground	09 Medium not Classified Above

Quantity Released(in pounds):

Fatalities:

Yes
No
Unknown

Number of Fatalities:

Injuries:

Yes
No
Unknown

Number of Injuries:

I have notified the following agencies of this report:

NDDES	State Fire Marshal
Local fire department	Local law enforcement
Local emergency manager	ND Department of Health
Other

General Description of
Incident and Actions:

By initialing here , I certify the information is a true, accurate, and complete description of the incident and actions taken regarding this incident.

This site updated as of 5/22/2012.