SPILL INCIDENT REPORT
To be completed by the Chemical Spill Responder or designee immediately following all hazardous spill response activities.
Section A: Contact Information
Section B: Description of the Event:
Date of Spill:
Time of Spill:
Medium or Media into which the release occurred:
Spill location (be specific, for example fume hood, counter, floor):
Building or Room:
What were the circumstances causing the spill?
List any existing or potential hazards that either caused or resulted from the incident:
What was the duration of the spill?
Section C: Spill Response Action Taken
Details of Containment & Clean Up Efforts:
Who completed the response?
Was the contaminated articles used for clean up sent to CCC for proper disposal?
Section D: Hazardous Material Information