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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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