Hazardous Materials Incident Response Checklist Form
Document a hazardous materials incident, response actions, current safety status, and follow-up needs.
Incident Details
Incident Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Incident Type or Scenario
*
Spill
Leak
Release
Fire
Exposure
Unknown Substance
Other
Reporting Person or Team Name
*
Hazardous Material Information
Substance or Material Name
*
Approximate Quantity or Volume
*
Container or Package Type
*
Please Select
Drum
Tank
Cylinder
Tote
Bag
Unknown
Other
Visible Labels, Placards, or Identification Details
Response Status and Actions
Current Containment Status
*
Contained
Partially Contained
Not Contained
Unknown
Immediate Hazards Observed
*
Fumes
Fire Risk
Spill Spread
Exposure Risk
Ignition Source
Environmental Runoff
Unknown
Protective Equipment Used by Responders
*
Gloves
Goggles
Face Shield
Respirator
Chemical Suit
SCBA
Other
Actions Already Taken
*
Decontamination / Disposal Status
Please Select
Not Started
In Progress
Completed
Not Applicable
Unknown
Follow-up / Escalation Needs
Submit Checklist
Should be Empty: