Casino Online Non AamsCasino Online Italia
EMERGENCY INCIDENT TELEPHONE LOG
Caller Information Caller Name: Date:
Caller Location: Time:
Incident Nature of Incident: Fire/Explosion

Chemical Spill

Gas Release

Injury/Illness

Severe Weather

Bomb Threat

Provide Specific Details:



Fire Emergency Information What is burning: Other Information
Chemical Emergency Information What is the spilled chemical? Where is the Spill?
How much spilled? Was anyone contaminated?
Medical Emergency Information Victim Name and Location: Nature of the Medical Problem:

Communication Response On-Site:

Security

ERT

First-Aid

Nurse/MD

 Off-Site:

Fire Dept.

Police Dept.

EMS

Other:



MAINTAIN LOG OF INCIDENT-RELATED COMMUNICATION
Time Called Caller Content
















SAFETY OFFICER'S CHECKLIST


Prepared By Call Number
Chemical ID Date
Quantity
Incident Location
Local Fire Department Notified? YES NO Temperature F
Risk Assessment Performed? YES NO Wind Direction (out of)


RESPONDER NAMES:

ENTRY 1_____________________________ 2______________________________

ENTRY 3_____________________________ 4______________________________

DECON 5_____________________________ 6______________________________

BACKUP 7_____________________________ 8______________________________

OTHER 9____________________________ 10______________________________

OTHER 11____________________________ 12______________________________

OTHER 13____________________________ 14______________________________

RESPONDER TEAMS
PRIMARY

ENTRY

 BACKUP

ENTRY

 PRIMARY

DECON

 BACKUP

DECON

 _______________ ______________ _______________
TEAM CHECK LIST: 1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 JEWELRY REMOVED
2 SCBA/RESPIRATOR
3 SUIT LEVEL(A,B,C,D)
4 BOOTS
5 GLOVES (TRIPLE)
6 TAPE
7 EYE PROTECTION
8 HARD HAT/SHIELD
9 FIRE PROTECTION
10 GAS MONITOR(S)
SUIT UP TIME
AIR ON TIME
TIME OUT
11 VITAL SIGNS






ASSESSMENT CHECKLIST

Date_______________________________

Call Number _______________________

HAZARDOUS MATERIAL INCIDENT

RISK ASSESSMENT




SUBSTANCE INFORMATION
CHEMICAL NAME UN/NA #
COMMON or TRADE NAMES EPA WASTE #
CHEMICAL FORM: SOLID LIQUID GAS REACTIVE (W/___________________________________) VOLUME or WEIGHT INVOLVED
IMMEDIATE HAZARDS:

FLAMMABLE

CORROSIVE

REACTIVE (W/____________________________)

RADIOACTIVE

INFECTIOUS

 MEASURED RISK PARAMETERS:

AIRBORNE CONCENTRATION (ppm)__________

PERCENT OF LEL__________________________

pH:______________________________________

ALL RELEASED SUBSTANCES MUST BE CONSIDERED TOXIC UNLESS OTHERWISE DETERMINED.


SITE INFORMATION
INDOOR OUTDOOR

ACCESS________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



ENVIRONMENTAL THREATS
TYPE:

STORM DRAIN

SOIL

PROPERTY LINE

 LOCATION TO INCIDENT:

____________________________________________________________________________________________________________________________________________________________________________________________________

SKETCH THE INCIDENT SCENE ON REVERSE SIDE


VICTIMS/PERSONNEL CONTAMINATION
IS ANYONE INJURED OR CONTAMINATED? YES NO

IF YES, DESCRIBE______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



LITERATURE BASED INFORMATION ON CHEMICAL, PHYSICAL & TOXICOLOGICAL PROPERTIES
INHALATION

INGESTION

OTHER____________________

FLASH POINT______________

SKIN ABSORPTION

EYE ABSORPTION

 CORROSIVE

CARCINOGEN

TERATOGEN

MUTAGEN

PESTICIDE

 FLAMMABLE: YES NO

LEL/LFL___________________

UEL/UFL__________________

 REACTIVITY:

WATER

AIR

ACID

CAUSTIC

OXIDIZER

OTHER__________________

 TLV__________________(ppm OR mg/m3)

PEL__________________(ppm OR mg/m3)

OTHER________________________________





BASED ON THE ABOVE INFORMATION, THE RISK IS ESTIMATED AS: HIGH LOW


PPE TO USE
GENERAL PROTECTION LEVEL:

LEVEL A

LEVEL B

LEVEL C

LEVEL D

 GLOVES:

NEOPRENE

NITRILE

PVC

LATEX

N-DEX

 BREATHING PROTECTION:

SCBA

AIR PURIFYING CARTRIDGE

_______________________

NONE

 HEAD PROTECTION:

YES NO ____________________

FOOT PROTECTION:

YES NO

____________________

 RESOURCES:

FIRE DEPARTMENT

SAFETY

MEDICAL

INDUSTRIAL HYGIENE







INCIDENT RESPONSE CHECKLIST

1. IMMEDIATE ACTIONS

a. Clear Affected area

b. Check for personal involvement

c. Establish a secure zone

d. Establish a COLD ZONE

e. Establish a Command Post

2. PERFORM RISK ASSESSMENT

a. Identify released material

b. Determine (estimate) quantity released

c. Evaluate hazards of the location

d. Evaluate the RISK

INITIATE ACTIONS TO MINIMIZE SPREAD - IF SAFE TO DO SO!


3. DEVELOP AN ACTION PLAN

a. Assign work tasks

b. Specify PPE Level

c. Specify needed equipment & tools

d. Establish WARM and HOT zones

e. Entry Team Tasks

(1) Confirm evacuation

(2) Measure Contaminant Levels

(3) Locate and control source

(4) Neutralize and/or adsorb material

(5) Prepare residue for removal

f. Verify area clear of contaminant

g. Decontaminate reusable equipment

h. Decontaminate and label waste

i. Decontaminate responders

4. TERMINATE INCIDENT

5. RESTOCK RESPONSE SUPPLIES

6. COMPLETE INCIDENT REPORTS

7. DEBRIEF RESPONDERS

INCIDENT COMMANDER WORK SHEET



Sketch the incident scene below and indicate the locations of your COLD LINE, WARM LINE, HOT LINE, DECON CORRIDOR, and COMMAND POST. Inidcate any locations of special concern, such as storm drains, run-offs, chemical storages, or similar potential problems.













INDICATE WIND DIRECTION:































INDICATE NORTH:



















































DECONTAMINATION CHECK LIST

(To be returned to I.C. for report purposes)


Date_______________________________

Call Number_________________________

Chemical Name___________________________________________________________


PPE LEVEL FOR DECON TEAM A B C
DECONTAMINATION TYPE WET DRY
EQUIPMENT
DECON EQUIPMENT Ground cover or Tarp

2 "pools"

5 five-gallon plastic buckets

Poly pads

2 Drums with liners

2 Brushes

Water supply

 Ground cover or Tarp

5 five-gallon plastic buckets

Poly pads

2 Drums with liners

SET-UP
PROCEDURES
EQUIPMENT REMOVAL SEQUENCE Outer gloves

Suit Rinse

Overboots

Suit Rinse

Hard hat

 Partial SCBA

Suit/Middle gloves

SCBA

Inner gloves

 Outer gloves

Overboots

Hard hat

Partial SCBA

 Suit/Middle gloves

SCBA

Inner gloves









LOGISTICS CHECKLIST

(To be returned to I.C. for report purposes)


Date_______________________________

Call Number 92-___________________

Chemical Name___________________________________________________________


RESPONSE PROCEDURES


PPE TO USE
GENERAL PROTECTION LEVEL:

LEVEL A

LEVEL B

LEVEL C

LEVEL D

 GLOVES:

NEOPRENE

NITRILE

PVC

LATEX

N-DEX

 BREATHING PROTECTION:

SCBA

AIR PURIFYING CARTRIDGE

_______________________

NONE

 HEAD PROTECTION:

YES NO ____________________

FOOT PROTECTION:

YES NO

____________________

 RESOURCES:

FIRE DEPARTMENT

SAFETY

MEDICAL

INDUSTRIAL HYGIENE



CLEAN-UP MATERIALS
ABSORBENTS:

ACTIVATED CARBON

POLYPROPYLENE PADS

MAGICSORB

OTHER_______________________________

 NEUTRALIZERS:

- ACIDS LIQUID ACID NEUTRALIZER

OTHER (oxidizers)_____________________________________________________________________

- CAUSTICS LIQUID CAUSTIC NEUTRALIZER

OTHER (oxidizers, stench, etc.)__________________________________________________________



TOOLS & SUPPLIES
SALVAGE DRUMS

SHOVELS

 DRUM PUMPS

FIRE EXTINGUISHERS

SQUEEGEE

BUNG WRENCH

MONITORS

DRUM LINERS

 55 GAL DRUMS

25, 16 GAL DRUMS

BROOMS



DECONTAMINATION STATION FUNCTION (describe):
NUMBER OF STATIONS:

1

2

3

MORE_______________

1._____________________________________________________________________________________________________________________

2._____________________________________________________________________________________________________________________

PRIMARY DECONTAMINATION MATERIALS:

WATER WATER PLUS DETERGENT SOLVENT___________________________________________________________________________________________________

SECONDARY DECONTAMINATION MATERIALS:

WATER WATER PLUS DETERGENT SOLVENT___________________________________________________________________________________________________



MEDICAL
B.P. CUFF FOR VITAL SIGNS CHECK DRINKING WATER FOR DEHYDRATION


DISPOSAL OPTIONS
DESCRIBE DISPOSAL PLAN:



DESCRIBE DISPOSAL PROBLEMS:









SPILL RESPONSE INFORMATION
Report Information Preparer Name: Date:
Preparer Title: Time:
Incident Description Chemical Releases:



Quantity Released:



Location of Release:

Provide Specific Details:



Cause of Release Be specific; use additional pages, if necessary.

Engineering Control Problems:



Work Practice Violations:



Personal Protective Equipment Problems:

Corrective Actions Should further steps be taken to prevent a recurrence. If so, what would the recommendations be?













Difficulties with Response Describe any difficulties or problems experience during response to this incident (i.e. poor team communications, spill response materials unavailable).











Employee Involvement List employees who where injured and/or contaminated during this incident. Describe emergency medical actions taken.







(This form is completed by Emergency Response Team Leader/Incident Commander within 24 hours after response is complete).

Explore these sites