Emergency Management Incident Report template

Please complete all sections and be as succinct and accurate as possible 1 Type of Situation (check ALL that apply) Incident Emergency Human-Created Natural 2 Employer Personnel Involved (check ALL that apply) Office personnel Fab or assembly operators Line maintenance Facility management ERT members Security Legal Counsel Human resources Senior management Other employer personnel Risk Management EH S 3 Equipment Involved (check ALL that apply) Fab or Assembly Equipment Process Piping Bulk Chemical Delivery System Process Gases Distribution System Specialty Gases System Facilities Systems HVAC Systems DI Water Abatement Systems 4 Nature of Situation (check ALL that apply) Chemical release or spill Fire Infrastructure failure (power HVAC utilities) On-site only (no off-site release or contamination) Local Community State National 5 Situation Statistics (please address the following areas in your Narrative Description) Geographic Location (generic by time zone) Physical location (fab facility office area other) Facility status at time of situation (normal shut down holiday preventative maintenance other) Date (begin end) Time (begin end) Conditions/Factors Related to Situation (weather operational status other factors that may impact the situation) NARRATIVE DESCRIPTION: 6 Summary Description of Situation Events (narrative please address the following areas in your response) Leading up to situation The situation itself The organization s response The organization s follow-up DESCRIPTION: 7 Response by ERT s Corporate Organization (narrative describe below) During situation itself After situation has returned to normal DESCRIPTION: 8 Impacts Attributed to Situation (check all that apply provide additional input in DETAILS AND DATA) Fatalities identify and quantify Any injuries identify and quantify Exposures to hazardous environments and/or materials identify and quantify Lost time or capabilities Off-site impacts DETAILS AND DATA: 9 Resources Used in Responding t