Fillable ONLINE REPORTING FORM (U.S. Chemical Safety and Hazard Investigation Board)

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ONLINE REPORTING FORM (U.S. Chemical Safety and Hazard Investigation Board)

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The ONLINE REPORTING FORM (U.S. Chemical Safety and Hazard Investigation Board) form is 6 pages long and contains:

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1
CSB Form 2020-01 Expiration Date: 04-30-2023
(4/30/20 ed.) OMB No.: 3301-0001
2
b5. Email
Provide the e-mail address for the person submitting the
report.
c1. Facility Name
Provide the name of the facility.
c2. Facility Street Address
Provide the address of the facility.
c3. City
Provide the city where the accidental release occurred.
c4. Zip Code
Provide the zip code of the facility reporting the accidental
release.
d1. Time of Accidental
Release
Provide the time of the accidental release.
d2. Date of Accidental
Release
Provide the date of the accidental release.
f. Indicate if one or more of
the following consequences
occurred during the
accidental release, and circle
all that apply, to the extent
known at the time of the
incident
Indicate the following consequences that best describes the
impact of your accidental release and check all that apply.
f1. Fire
A fire is the combustion of flammable materials producing
light, flames, and heat.
f2. Explosion or deflagration
An explosion is a rapid chemical reaction with the
production of noise, heat, and violent expansion of gases,
whether supersonic (explosion) or subsonic (deflagration).
f3. Death
Any fatality resulting from the accidental release.
f4. Serious Injury
Any in-patient hospitalization resulting from the accidental
release (OSHA 1904 subpart E).
f5. Property damage
Mark “Yes” if the accidental release resulted in damage to
facility property (equipment, buildings, piping, storage
tanks etc.,); otherwise, mark “No”
g. List All Chemicals
Released
Provide the Chemical Abstracts Service (CAS) name and
number or International Union of Pure and Applied
Chemistry, IUPAC name and number or other appropriate
chemical identifier name and number of all chemicals
released during the accidental release.
g1. Name CAS
Enter CAS or other chemical identifier name and number.
g2. Name CAS
Enter CAS or other chemical identifier name and number.
h. Amount of chemical(s)
named in g, released during
the accidental release, if
known – list chemical name
and quantity released (use
additional paper if necessary)
Provide the quantity of all chemicals released in the form of
a list.
CSB Form 2020-01 Expiration Date: 04-30-2023
(4/30/20 ed.) OMB No.: 3301-0001
3
h1. Quantity Released
Provide the amount of the chemical released during the
accidental release.
h2. Quantity Released
Provide the amount of the chemical released during the
accidental release.
i1. Number of Fatalities
Provide a count of the employees, contract workers or
members of the public fatally injured from the accidental
release (clearly distinguish the impact on each group).
j1. Number of Serious
Injuries
Provide a count of the employees, contract workers or
members of the public seriously injured from the accidental
release.
k. Estimated property
damage at or outside the
stationary source
Provide information on property damage on site and/or
outside the fence line of the stationary source.
l. If known, did the
accidental release result in an
evacuation order to members
of the general public or
others?
Provide information on any evacuation order issued as a
result of the accidental release.
l1. Evacuation
Indicate the number of employees and/or members of the
general public evacuated due to the accidental release, if
known at the time this report is issued.
l2. Approximate radius of
evacuation zone
Provide information on the approximate radius of the
evacuation zone (i.e., 1 mile), if known at the time this
report is issued
l3. Type of individuals
subject to evacuation order
(i.e., employees, members of
the general public, or both).
Circle all that apply.
Provide information on the type of individuals subject to the
evacuation order. Circle all that apply. (If only employees
were affected, only circle “Yes.” If both employees and the
general public were evacuated, circle “Yes” for each.
Signature
Provide the signature of the person filling out the form.
Print Name
Print the name of the person filling out the form.
Last name
Provide the last name of the person filling out the form.
First name
Provide the first name of the person filling out the form.
CSB Form 2020-01 Expiration Date: 04-30-2023
(4/30/20 ed.) OMB No.: 3301-0001
4
Public Burden Information
This collection of information is estimated to take an average of fifteen minutes per response,
including time for reviewing the instructions, gathering the data needed, and completing the
form. This is a mandatory collection under 40 C.F.R. § 1604. Pursuant to the Paperwork
Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to
respond to, a collection of information unless it displays a currently valid OMB control number
(that number OMB 3301-0001, is displayed here and in the upper right-hand corner of the first
page of this CSB Form 2020-1). Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the
General Counsel, Chemical Safety and Hazard Investigation Board, Suite 910, 1750
Pennsylvania Ave., NW. Washington, DC, 20006.
CSB Accidental Release Reporting Form
a1. Name of Owner/Operator: a2. Name of Owner/Operator Contact:
a3. Title of Owner/Operator Contact: a4. Mobile Phone Number:
a5. E-mail address: a6. Office Phone Number:
b1. Name of Person Submitting Report:
b2. Title:
b3. Mobile Phone Number: b4. Office Phone Number:
b5. Email:
c1. Facility Name:
c2. Facility Street Address: c3. City: c4. Zip Code:
d1. Time of Accidental Release: d2. Date of Accidental Release:
e. Describe the accidental release. Include equipment pressure, temperature and quantity of
materials in process and released prior to and after the incident.
f. Indicate if one or more of the following occurred during the accidental release.
Circle all that apply, to the extent known:
f1. Explosion: Yes No
f2. Fire: Yes No
f3. Death: Yes No
CSB Form 2020-01 Expiration Date: 04-30-2023
(4/30/20 ed.) OMB No.: 3301-0001
5
f4. Serious Injury Yes No
f5. Property damage Yes No
g: Name of the materials involved in accidental release using the Chemical Abstract Service
(CAS) number(s) or other appropriate identifiers. (Add more lines if more than two chemicals).
g1. Name CAS:
g2. Name CAS:
h. Amount of chemical(s) named in g, released during the accidental release, if known. List
chemical name and quantity released. Use additional paper if necessary.
h1. Quantity released:
_______________________________________________________________
h2. Quantity released:
_______________________________________________________________
i1. Number of Fatalities:
j2. Number of Serious Injury(ies):
k. Estimated property damage at or outside stationary source.
l. If known, did the accidental release result in an evacuation order to members of the general
public or others?
l1. Number of people evacuated:
l2. Approximate radius of evacuation zone:
l3. Type of individuals subject to evacuation order (i.e., employees, members of the general
public, or both). Circle all that apply.
Employees evacuated Yes No
General public evacuated Yes No
CSB Form 2020-01 Expiration Date: 04-30-2023
(4/30/20 ed.) OMB No.: 3301-0001
6
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Completed 25 January 2021

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