Incident Date*

Incident Time*

Discovery Date

Discovery Time

Reporter Name*

Reporter Title

Reporter Phone

Incident Location*

Incident Description*

Material Type*

Material Name / Product

Estimated Quantity Released*

Cause of Release*

Release Still Active*

Estimated Area Affected

Hazardous Material (CERCLA/RCRA)

Reportable Quantity Exceeded

Containment Actions Taken*

Containment Successful*

Cleanup Description

Waste Generated (type / quantity)

Disposal Method

Disposal Facility Name

Cleanup Complete*

NRC Report Number

Initial Notification Date/Time

Agency Contact Person

Notification Method

Notification Notes

Follow-Up Sampling Required

Written Report Required

Preventive Measures / Recommendations

Root Cause Analysis

Additional Notes

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