Person completing this form

Name

Title

Telephone

Address

1.Type of dangerous occurence (check all applicable boxes)

Spill

Leak

Explosion

Fire

Contamination of

Human

Property

Environment

2.Date of dangerous occurence (yyyy-mm-dd)

3.Time of dangerous occurence (24 hour System)

4.Location of dangerous occurence (be specific)

5.

Residential area

Commercial and residential area

Urban core area

Industrial area

Riral area

6.Dangerous occurence happened

During transport

During handling (specify)

During temporary storage

Other (specify)

Quantity

7.Complete A or B

A

Dangerous occurence during transport

(1).Mode of transport

Road

Rail

Air

Marine

(2).Type of vehicle

(3).Carrier (name and address)

B

Other (specify)

(2).Facility (name and address)

8.Consignor

Name

Address

9.Origin of consignement

10.Destination of consignement

11.Destination of consignement

P.I.N.

Classification

Shipping name

Type of package

Total mass or volume of shipment

Mass or volume of estimed loss

12.Describe the events leading to during and resulting from the dangerous occurrence

13.Number of deaths

14.Number of injured persones requiring hospitalization

15.Evacuation of surrounding area

Yes

No

If yes : (a) Number of people evacuated

(b) Duration of evacuation

16.Emergency response personnel at site of dangerous

Police

Fire department

Other