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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
AM/PM
Who received the initial notification/call?
University Police
Environmental Health & Safety
Emergency Management & Mission Continuity
Individual Person (call or email)
Individual's Name
First
Last
This is the original person who received the call or email information.
Caller's Name
First
Last
Caller's Phone #
*
Incident Location
*
Building and Room or nearest intersection
What department(s) if any, own the location of the spill?
Nature of Incident
*
Gas Alarm
Chemical Material
Vehicle Leaking Fluid
Radioactive Material
Biological Material
Odor Investigation
Explosion/Fire
Water related
Other
(Hold the "CTRL" key to select more than one hazard)
Which teams responded?
Environmental Health & Safety
Emergency Management & Mission Continuity
Facilities
Fire & Life Safety
Insurance & Risk Management
University Police
(Hold the "CTRL" key to select more than one)
Other departments or units that responded
This includes outside responders (Fire, Police, EMS), department/unit/college representatives.
List all NC State Personnel involved in response, including consultation and recovery.
First name
Last name
Department
Click the "+" to add personnel
What was the cause of the incident?
*
Causal information is considered preliminary until the full review is complete.
Please describe the incident and associated information.
Additional details can be added to the final report.
List any department/college contacts made at the time of response.
First name
Last name
Department
Click the "+" to add contacts
Were any vendors contacted for hazardous material cleanup activities?
Yes
No
Vendor(s) contact information.
Was hazardous waste generated?
*
Yes
No
If yes, who submitted the waste in EHSA?
First
Last
This should be a department representative, unless it is EHS related waste.
Do replacement response and clean up supplies need to be ordered?
Yes
No
If yes, contact Karen Trimberger.
Do you have pictures or documents from the incident?
Yes
No
Save all supporting documentation and photos to Google Drive (Campus Emergencies)
Was the scene released at the time of the incident?
Yes
No
If not, include any additional information or next steps needed in the general comments box below.
Is further clean up/repair/investigation/training needed from this incident?
Yes
No
Review of safety plan information will determine if training is incomplete/deliquent for the event.
General comments
Describe further action needed or general comments that support the event's response.
Comments
This field is for validation purposes and should be left unchanged.