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Significant Event
Name
First
Last
Email
Location
Street address or intersection preferred
Department
Phone - immediate contact #
Do occupants need assistance?
Yes
No
Unknown
Summary of Impact
Is area accessible by vehicle?
Yes
No
Unknown
Do occupants need assistance?
Yes
No
Unknown
Are there any hazardous conditions of concern?
Hazardous Materials
Egress hazards?
Odor concerns?
Vehicle egress hazards?
Natural disaster concerns?
Other
Other Hazardous Conditions
Utilities
Is there power?
Yes
No
Unknown
Is there potable water?
Yes
No
Unknown
Is there network connectivity?
Yes
No
Unknown
Response
Which campus departments have been notified?
Emergency Management & Mission Continuity
Environmental Health and Safety
Facilities Operations
Fire & Life Safety
Insurance and Risk Management
University Police
Other
Other Departements
Phone
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