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Incident Information Worksheet

 This worksheet should be completed by the Incident Commander, or an appointed representative, during the time of the incident. This information will be useful to emergency responders, medical personnel, government agencies, and post-incident cleanup personnel.

 

Date & Time of Incident: _____/_____/_____ _____:_____ am / pm (circle one)

Location of Incident: _____________________________________________________

Incident Number: _____-______________

IDEM Number: _________________________________________________________

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Hazardous Material(s) Involved: ___________________________________________

NOTE: If more than 1 material is involved use multiple copies of this form!!!

Hazardous Nature of Material(s) Involved (Mark all that apply):

NFPA 704

______Flammability ______ Toxicity H _______ (1-4)

______Combustible ______ Solid F _______ (1-4)

______Reactivity ______ Liquid R _______ (1-4)

______Corrosivity ______ Gas S ________________

______Other: ___________________________________________________

Amount Released: ___________________________________ lbs. / gallons (circle one)

Is the released product contaminating, ______ Ground, ______ Water or ______ Air

Type of Container System Involved:

______ Drum ______ Box ______ Motor Fuel Tank ______ Bulk Storage Tank

Other: ___________________________________________________

Brief Description of Incident: ______________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Name of Spiller: _________________________________________________________

Address: ________________________________________________________

City: _________________________________ State _____ Zip _____________

Contact: __________________________________________________________

Direct Phone: ___________________________ Pager:_____________________

Responsible Party on Scene: __________________________________________

Clean-up Authorization Number: ______________________________________

Does SPILLER have clean-up/response capabilities ______ YES ______ NO

Has SPILLER selected a Spill Clean Up Contractor ______ YES ______ NO

Who Made Selection: _______________________________________________

Responding Contractors:

Company Name Time Notified Time Arrived Signature of Responsibility

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The signature below signifies that the spiller has entered into a contract with the named company(s) (Contractor(s)) to provide site clean-up.

Spiller Authorizing Clean-up, Signature:_______________________________________

Responding Agencies:

q IDEM (Indiana Department of Environmental Response) (888) 233-7745

Contact Name: ______________________________ Phone: _________________

______ SEMA (State Emergency Management Agency) (800) 669-7362

Contact Name: ______________________________ Phone: _________________

______ IERC (Indiana Emergency Response Commission) (800) 669-7362

Contact Name: ______________________________ Phone: _________________

______ NRC (National Response Center) (800) 424-8802

Contact Name: ______________________________ Phone: _________________

______ Other:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Injury Report

Number of Persons Injured/Killed: _____________________________________

Names of Persons Injured/Killed: ______________________________________

__________________________________________________________________

__________________________________________________________________

If injured persons are being taken to the hospital, have someone call the hospital immediately so that they may set up their own decontamination system.

Evacuation/Protection-In-Place Procedures Implemented:

Location

Start Time

End Time

Notified By

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Information Resources Used:

Is clean up under way: ______ YES ______ NO

Is clean up complete: ______ YES ______ NO

Incident Commander: ____________________________________________________

Time of Incident Termination: ___________________ am / pm (circle one)