ࡱ > k n j ~ bjbjss 4l 8 D [ , v v v e g g g g g g $ j! R v v v v v 8 8 8 v ^ e 8 v e 8 8 u 0l d Q 0 , ! 8 ! ! v v 8 v v v v v 8 v v v v v v v ! v v v v v v v v v : Public Health Unit Chemical/Pollution Incident Notification Form
Name of person making notificationDate of notificationTime of notificationNotifiers organisationPositionNotifiers contact numberEmail
Has the Fire Service attended the scene?Y / NHas Ambulance attended the scene?Y / NWhat is the EPA reference number?
Description of incident (information to be obtained from the notifier)
What happened and what is contaminated? (e.g. a spill of liquid or leak of gas contaminating air, water, land, food etc.)What is the contaminating material? (e.g. a chemical compound, biological or radiological material)Name and UN number (if applicable)Chemical formulaVolumeConcentration Where and when did the incident happen? Address or location of incidentDistance to nearest residenceDistance to nearest business Time release beganIs the release ongoing?Y / NIs the release contained? If no, what action is being taken to contain the release?Has any contaminated solid, liquid, gas or airborne material gone off site? (provide details)Is there a plausible mechanism by which people have been / may be exposed to the contaminating material?
Has anyone complained of health effects?Y / NHas anyone been hospitalised?Y / NIf yes:Who is unwell?WorkersY / NLocal residentsY / NHow many people are affected?WorkersLocal residentsWhat are the symptoms?Where were the affected people?
If there is any doubt about whether the incident could result in a plausible route of exposure, the EPA should be contacted to provide clarification. The Regional Duty Officer may be contacted via the Environment Line (131555)
Additional information may be recorded here:
Is further action required?
Further action is most likely to be required if there are complaints of health effects or if contamination has spread beyond the site boundary and there is a plausible mechanism of public exposure.Y / N
If yes, go to form 2 (under development). Immediate notification of the LHD HSFAC should be considered.
Name of person completing formDateSignatureTime
Local Health DistrictTime taken to assess this notification
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