Incident Response Notification Form – Emergency Management & Mission Continuity

Email of person submitting this report*

Date of call*

Time fo call

:

Who received the initial notification/call?

University Police
Environmental Health & Safety
Emergency Management & Mission Continuity
Fire & Life Safety
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*

(Hold the "CTRL" key to select more than one hazard)

Which teams responded?

(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 if EHS, William Stanfield for FLS.

Do you have pictures or documents from the incident?

Yes
No

Save all supporting documentation and photos to Google Drive (Campus Emergencies Folder)

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.

Name

This field is for validation purposes and should be left unchanged.