PHMSA Hazmat Home

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PART II - GENERAL INCIDENT INFORMATION 3. Date of Incident: From: To: (mm/dd/yyyy) 7. Location of Incident: City: (contains) State: Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia FOREIGN Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana N. Mariana Islands Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas UNKNOWN Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: (contains) Incident Route: (contains) 8. Mode of Transportation: Air Highway Rail Water Other 9. Transportation Phase: In Transit Loading Unloading In Transit Storage 10. Carrier/Reporter Name: (contains) State: Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia FOREIGN Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana N. Mariana Islands Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas UNKNOWN Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: (contains) 11. Shipper/Offeror Name: (contains) 12. Origin: City: (contains) State: Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia FOREIGN Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana N. Mariana Islands Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas UNKNOWN Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: (contains) 14. Proper Shipping Name of Hazardous Material: (contains) 16. Hazardous Class/Division Code: (begins) 17. Identification Number: (contains) PART III - PACKAGING INFORMATION 24. Packaging Type: Non-Bulk IBC Cargo Tank Motor Vehicle (CTMV) Tank Car Cylinder RAM Portable Tank Other 25. Incident Cause: What Failed: (contains) How Failed: (contains) Causes of Failure: (contains)

PART IV - CONSEQUENCES 30.Result of Incident: Spillage Fire Explosion Material Entered Waterway/Storm Sewer Vapor(Gas) Dispersion Environmental Damage No Release 33a. Did the hazardous material cause or contribute to a human fatality? Select YES NO 36. Was a major transportation artery or facility closed? Select YES NO 34. Did the hazardous material cause or contribute to personal injury? Select YES NO 37. Was the material involved in a crash or derailment? Select YES NO 35. Did the hazardous material cause or contribute to an evacuation? Select YES NO

OTHER Report Number: (contains) Serious Incident: Select YES NO Container Code Detail: (contains) Undeclared Shipment: Select YES NO General Package Type: Select BAG BAG CLOTH BAG PAPER BAG PLASTIC BARREL/KEG WOOD BATTERY BOTTLE BOX BOX FIBER BOX METAL BOX MULTI-WALL BOX PLASTIC BOX WOOD CAN CARBOY COMPOSITE CONTAINER CYLINDER CYLINDER BULK CYLINDER TRL DRUM DRUM METAL DRUM NON-METAL GENERAL HOPPER IBC IBC CONTAINER INSIDE CONTAIN JAR JERRICAN JUG KEG METAL LAB PACK MIL ORD NON-BULK OTHER PAIL RAM CONTAINER TANK TANK CAR TANK CAR CRYO TANK CRYO TANK INTERMODAL TUBE

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