Incident Response Reporting Form – Emergency Management & Mission Continuity

Email of person submitting this Report*

Date of call*

Time of call

:

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
Unknown

Caller's Name

First Last

Callers Phone #

(Prefer cell #)

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/depts responded

(Hold the "CTRL" key to select more than one agency/dept)

Other agencies/departments

List all NC State Personnel involved in response, including consultation and recovery

First Name	Last Name	Department

click the "+" button 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 "+" button to additional contacts

Were any vendors contacted for hazardous materials 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 "+" button 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/repair/billing?

Yes
No

Who was notified?

(Click the "+" button to add additional contacts)

First Name	Last Name	Department

Date of Notification

Is further clean up/repair/investigation/training needed from this incident?

Yes
No

Describe further actions needed

Comments

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