CSB Form 2020-01
(4/30/20 ed.)

Expiration Date:04-30-2023
OMB No.: 3301-0001

Public Burden Information

This collection of information is estimated to take an average of fifteen minutes per response, including time for reviewing the instruction, gathering the data needed, and completing the form. This is a mandatory collection under 40 C.F.R & 1604. Pursuant to the paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to respond to, a collection of information unless it displays a currently valid OMB control number (that number OMB 3301-0001, is displayed here and in the upper right-hand corner of the first page of this CSB Form 2020-1). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the General Counsel, Chemical Safety and Hazard Investigation Board, Suite 910, 1750 Pennsylvania Ave., NW. Washington, DC, 200006.

CSB Accidental Release Reporting Form

e. Describe the accidental release. Include equipment pressure, temperature and quantity of material in process and released prior to and after the incident.

Spell Check

f. Indicate if one or more of the following occurred during the accidental release

Select all that apply, to the extent known:

g. Name of the materials involved in accidental release using the Chemical Abstract Service (CAS) number(s) or other appropriate identifiers. (Use additional field if more than two chemicals.)

h. Amount of chemical(s) named in g, released during the accidental release, if known. List chemical name and quantity released. Use additional field if necessary.

Spell Check

l. If known, did the accidental release result in an evacuation order to members of the general public or others?.

l3. Type of individuals subject to evacuation order (i.e., employees, members of the general public, or both). Select all that apply.