Hazardous Materials Notification Form

Email of person submitting this report*
Date of call*
MM slash DD slash YYYY
Time fo call

: Hours

Minutes

AM/PM
Who received the initial notification/call?
- University Police
- EHS
- Individual Person
Individual's Name
First Last
Was University Police contacted by any party?
- Yes
- No
Caller's Name
First Last
Callers's Phone #*
Incident Location*

Building and Room or nearest intersection
What department(s) if any, own the location of the spill?
Nature of Incident*
(Hold the "CTRL" key to select more than one hazard)
Other hazard
Which agencies/dept responded
Other agencies/departments
List all NC State Personnel involved in response, including consulation and recovery
First name Last name Department

Click the "+" to add personnel
What was the cause of the incident?*
What is your assessment of the incident?
Please detail any after action or corrective measures taken
Name all departmental contacts made during the incident
First name Last name Department

Click the "+" to add contacts
Were any vendors contacted for hazardous material cleanup activities?
- Yes
- No
Vendor(s) contacted
Was hazardous waste generated?*
- Yes
- No
Submitted in EHSA by:
First Last
Do replacement response and clean up supplies need to be ordered?
- Yes
- No
List of supplies needed

Click the "+" to add items
Do you have pictures or documents from the incident?
- Yes
- No
Are they saved to Google Drive/Spill Response/Incident folder?
- Yes
- No
Was the scene released?
- Yes
- No
Was the space owner/department notified after the event for scene release/repeairs/billing?
- Yes
- No
Who was notified
First name Last name Department

Click the "+" to add additional contacts
Date of notification
MM slash DD slash YYYY
Is further clean up/repair/investigation/training needed from this incident?
- Yes
- No
Describe further action needed
Name
This field is for validation purposes and should be left unchanged.

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First name	Last name	Department

First name	Last name	Department

First name	Last name	Department