D- Data Collection - Word

Attachment D:

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

National Toxic Substance Incidents Program (NTSIP)

STATE DATA COLLECTION FORM

10 DIGIT EVENT IDENTIFICATION NUMBER __ __ __ __ ___ ___ ___ ___ ___ ___

Entry Date __ __ /__ __ /__ __ __ __

1. Based on the NTSIP case definition, is this event eligible?

1 = Yes

2 = No

3= Uncertain

If “No” was selected, please choose one of the following reasons why:

[1] Hoax

[2] Petroleum, no public health action or victim

[3] Small quantity

[4] Chronic

[5] Insufficient information

[6] Not a hazardous substance

[7] Controlled/legal/permitted release

[8] Duplicate

[A] No release, no public health action

[B] Suspicious activity (potentially terrorism)

[C] Not a potential NTSIP event (NTSIP just being used to capture data)

[D] Other ______________________________________________

[E] Home incident, no public health action

[F] Stack release, no public health action or injury

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

NOTIFICATION

2. Date that the state NTSIP staff was notified of the event. __ __ /__ __ /__ __ __ __

3. Who first notified the state health department? Select from source picklist

1. Source from picklist _______ event id associated with source_____________________

What other additional sources of data were used?

2. Source from picklist ______ event id associated with source_______________________

3. Source from picklist ______ event id associated with source_______________________

4. Source from picklist ______ event id associated with source_______________________

Source Picklist

[0] Media

[1] On scene commander/incident commander or staff (e.g., fire, police, EPA)

[2] Health agency other than the state health dept

[4] Environmental department or division

[5] Emergency government/emergency services

[6] Citizen or citizen's group

[7] Owner/operator of facility, vehicle, or vessel

[8] Other _______________(15)

[9] Unknown

[A] DOT/HMIS

[B] Other government agency

[C] Other program within state health department

[D] Hospital or Hospital dataset

[E] Poison Control Center

[F] National Response Center

[G] ACE team

DESCRIPTION

4. What was the date of this event? (MM/DD/YYYY) __ __ -__ __ -__ __ __ __

Pick from calendar

5. What time did the event start? Use 24‑hour time format. If unknown, leave blank and select a time category.

____ ____ : ____ _____

Time category

1 = 00:00 am - 05:59 am

2 = 06:00 am - 11:59 am

3 = 12:00 pm - 05:59 pm/12:00-17:59

4 = 06:00 pm - 11:59 pm/18:00-23:59

EVENT LOCATION

6. Where did the event start? (If exact street address is not known, enter cross streets, highway mile marker, railroad crossing etc. Record where it first started)

Multiple locations were contaminated [ ] Yes [ ] No

___________________________________________________________________

Street address (encrypted)

______________________ _____(2)

City State

______________________

County

_________(5)

Zip Code

>Press D button to retrieve the latitude and longitude from the computer.

>Check box to choose whether you want the identifying information encrypted or not

7. Was this a private vehicle or residence? [ ] Yes [ ] No (if yes, skip to question 9)

8. Event Location Name (encrypted)______________________________________

NAICS code from computer dropdown __ ___ ___ ___ ___ ___

Industry description_____________________________________________________

9. Is the location listed in Question 8 the same as the industry (or entity) that caused the hazardous substance(s) release?

1 = Yes (Go to #11)

2. = No

10. Responsible industry name (encrypted)_________________________________________

NAICS code from computer dropdown __ ___ ___ ___ ___ ___

Industry description_____________________________________________________

AREA/FACTORS

>Use P button on computer to determine ¼ mile proximity to sensitive subpopulations.

11. What is the GENERAL land use in the surrounding area? (ONE or TWO entries.)

[0] Undeveloped area

[1] Industrial area

[2] Commercial area

[3] Residential area

[4] Agricultural area

[A] Military facility/DOE/DOD

[C] Recreational area

12. Factors contributing to the release: (If primary unknown leave blank. Use Specify and Other to provide more detail on the primary and secondary factor)

Secondary Factor

[N] No secondary

[2] Equipment failure

[3] Human error

[8] Other __________(15)

[G] Intentional

[H] Bad weather conditions/natural disasters

[S] Illegal act

Specify

[1] Improper mixing

[2] Valve failure

[3] Ruptured pipeline

[4] Improper filling, loading, or packing

[5] Extreme heat

[6] Extreme cold

[8] Other ___________________(15)

[A] Performing maintenance

[B] System/process upset

[C] System start up and shutdown

[E] Power failure/electrical problems

[F] Unauthorized/improper dumping

[I] Vehicle or vessel collision

[J] Fire

[K] Explosion

[L] Overspray/misapplication

[M] Weather disaster (hurricane, tornado, flood)

[N] Lightning

[O] Loadshift

[P] Vehicle or vessel derailment/rollover/capsizing

[Q] Illicit drug production related

[R] Forklift puncture

[S] Aging machinery

[T] Impact with sharp/protruding object

[U] Loose closure, component, or device

[V] Vandalism

[W] High winds

[X] Rain

[Y] Snow, ice, sleet, hail

[Z] Fog or mist

Primary Factor

[2] Equipment failure

[3] Human error

[8] Other __________(15)

[G] Intentional

[H] Bad weather conditions/natural disasters

[S] Illegal act

Specify

[1] Improper mixing

[2] Valve failure

[3] Ruptured pipeline

[4] Improper filling, loading, or packing

[5] Extreme heat

[6] Extreme cold

[8] Other ___________________(15)

[A] Performing maintenance

[B] System/process upset

[C] System start up and shutdown

[E] Power failure/electrical problems

[F] Unauthorized/improper dumping

[I] Vehicle or vessel collision

[J] Fire

[K] Explosion

[L] Overspray/misapplication

[M] Weather disaster (hurricane, tornado, flood)

[N] Lightning

[O] Loadshift

[P] Vehicle or vessel derailment/rollover/capsizing

[Q] Illicit drug production related

[R] Forklift puncture

[S] Aging machinery

[T] Impact with sharp/protruding object

[U] Loose closure, component, or device

[V] Vandalism

[W] High winds

[X] Rain

[Y] Snow, ice, sleet, hail

[Z] Fog or mist

TRANSPORTATION/FIXED FACILITY

13. What type of event was this?

[1] Transportation

[2] Fixed facility (Go to #16)

14. What mode of transportation was involved? (ONE or TWO entries.)

[2] Ground (choose tanker truck, non-tanker truck, van, automobile, bus, other)

[3] Rail (choose container on flat car, tank car, box car, other)

[4] Water (choose container ship with own power, tanker ship with own power, barge towed by other vessel, other)

[5] Air (choose crop duster, cargo plane, passenger plane, other)

[6] Pipeline

15. What phase of transportation was involved?

[1] Occurred during unloading of a stationary vehicle or vessel

[2] From a moving vehicle or vessel

[3] Enroute that was later discovered at a fixed facility

[4] From a stationary vehicle or vessel (e.g, staged at transfer station)

[8] Other _______________(15)

16. What area/equipment of the fixed facility was involved in the event? (ONE or TWO entries.) Use “Other” to describe the area better if desired.

[0] Transportation within fixed facility

[2] Process vessel

[3] Piping

[4] Material handling area (i.e. loading dock)

[5] Storage area above ground (i.e. warehouse, tank, storage shed)

[6] Storage area below ground

[7] Dump/waste area (i.e. sewer)

[8] Other (specify)____________________________________________________(15)

[A] Ancillary process equipment

[B] Transformer or capacitor

[C] Incinerator

[D] Heating/cooling for building

[J] Laboratory

17. Did the release impact:

1 = Inside a closed structure only

2 = Outside of a closed structure only

3 = Both inside and outside of a closed structure

SUBSTANCE(S)

Complete questions # 18-23 for each substance, attach extra pages if necessary.

18. Substance Makeup

Type

[ ] Individual

[ ] Mixture-pick > 1 component

[ ] Reaction-pick reactants and product

Chemical (s) (use picklist)

_______________________________________________________________(37)

Complete below only if the chemical name is not on the pick list.

Chemical Abstract Service (CAS) number ______________

Department of Transportation (DOT) United Nations (UN) number __________

Manufacturer/other information ______________________________________________

Substance Category (choose 1)

[1] Acids

[10] Other

[2] Ammonia

[3] Bases

[4] Chlorine

[5] Other inorganic substances

[6] Paints and dyes

[7] Pesticide/Agricultural

[8] PCB’s

[9] VOC’s

[A] Formulations

[B] Hetero-organics

[C] Hydrocarbons

[D] Oxy-organics

[E] Polymers

19. Was the substance

[1] Actually released into the environment.

[2] Threatened to be released into the environment.

20. Was this substance used as a pesticide (not classified as a pesticide but used in that capacity)?

[1] Yes

[2] No

21. Type of release (May have ONE or TWO entries.)

[1] Spill (liquid or solid)

[2] Volatilization/aerosolized (vapor)

[3] Fire

[4] Explosion

[5] Radiation

[7] Not applicable, threatened release

22. Quantity released

[A] = <1

[B] = 1- <10

[C] = 10- < 100

[D] = 100- < 500

[E] = 500 - < 1,000

[F] = 1000 - < 10,000

[G] = 10,000 +

23. Unit of measure (to complete question 35).

[1] Pounds

[2] Kilograms

[3] Gallons

[4] Liters

[5] Cubic feet

[6] Ounces by volume

[7] Milliliters

[8] Pico curies

[A] Tons (metric)

[B] Ounces by weight

[C] PPM (parts per million)

VICTIMS

24. How many people were injured in this event ? __ __ __ __ (If none enter 0 and skip to Q26)

25. Complete A-F for Victim 1-n, attach extra pages if necessary.

A. Category of victim

[1] Employee

[2] Responder (not specified)

[3] General public

[A] Career firefighter

[B] Volunteer firefighter

[C] Firefighter (not specified)

[D] Police officer

[E] EMT personnel

[F] Hospital personnel (e.g., doctor, nurse)

[G] Employee is member of company response team

[H] Student (at school)

[I] 3^rd Party Clean-up Contractor

B. (If the victim is a responder) Is the victim a certified HazMat technician?

[1] Yes

[2] No

[3] Not a responder

C. Severity and disposition of victim

[2] Treated on scene (first aid)

[3] Treated at hospital (not admitted)

[4] Treated at hospital (admitted)

[5] Observation at hospital; no treatment

[6] Seen by private physician within 24-hours

[7] Injuries experienced within 24 h of event and reported by official (e.g., fire dept, EMT)

[8] Treated by mass casualty mobile unit

[A] Death on scene/on arrival at hospital

[B] Death after arrival at hospital

[C] Treated at hospital (admission unknown)

D. Adverse health effects (may be up to seven entries--see training manual for instructions)

[A] Trauma (choose type: chemical-related, not chemical-related, both or unknown)

[B] Respiratory system problems

[C] Eye irritation

[D] Gastrointestinal problems

[E] Heat stress

[F] Burns (choose type: thermal, chemical, both, or unknown)

[H] Other _______________(10)

[I] Skin irritation

[J] Dizziness or other CNS symptoms

[L] Headache

[M] Heart problems

[N] Shortness of breath (unknown cause)

E. Personal Protective Equipment (PPE) ‑‑ What level of PPE was the victim using prior to being harmed or killed? (Choose the 1 option that best describes)

[1] None

[2] Level "A"

[3] Level "B"

[4] Level "C"

[5] Level "D"

[6] Fire fighter turn‑out gear with respiratory protection

[A] Fire fighter turn‑out gear without respiratory protection

[B] Other types of protection (select gloves, eye protection, hard hat, steel-toed shoes)

F. Age of victim

[1] Child under 18 years old

[2] Adult 18 years old or greater

G. Decontamination of injured person

[1] None

[2] At the scene

[3] At a medical facility

[4] Both scene and medical facility

DECONTAMINATION /POPULATION AFFECTED

An individual may be counted in both categories if they were decontaminated at both locations.

26. Total number of people decontaminated on scene

0=0

1=1-5

2=6-20

3=21-50

4=51-100

5=101-500

6=501-1000

7=>1000

27. Total number of people decontaminated at medical facility

0=0

1=1-5

2=6-20

3=21-50

4=51-100

5=101-500

6=501-1000

7=>1000

Use computer demographics button to complete number of people living in a ¼, ½ and 1 mile radius.

28. Did the event affect any of the following routes of transportation? (Select all that apply)

[1] Interstate/freeway

[2] Arterial roads

[3] Local roads

[4] Waterway

[5] Railroad/Railyard

[8] Other _______________ (15)

[A] None

EVACUATION AND IN-PLACE SHELTERING

29. Did an evacuation occur?

1 = Yes

2 = No (Go to question 31)

30. What is the total number of people evacuated?

1 = less than 5

2 = 5-20

3 = 21-50

4 = 51-100

5=101-500

6=501-1,000

7= greater than 1,000

31. Did an official order in‑place sheltering? (that is, to stay indoors rather than evacuating)

1 = Yes

2 = No

32. Was access to the area restricted in any way? (Select all that apply.)

[1] No restriction

[4] Building or part of

[5] Facility

[6] Parking lot

[7] Access route/road

[8] Other adjacent areas

RESPONSE

33. Activities taken to protect public health as a result of this event? (Choose ONE or TWO)

[1] Health advisory issued

[2] Well survey conducted

[3] Alternative water provided

[4] Fishing and/or water recreation ban

[5] Discourage/prohibit consumption of locally grown produce and livestock

[6] Health investigation (epidemiological study, medical monitoring over time, exposure assessment)

[7] Environmental sampling

[8] Other _______________(15)

[9] Shutdown of water intakes

[10] None

34. Who responded to this incident? (Select all that apply.)

[1] No response

[2] Certified HazMat team

[3] Company’s response team

[4] Law enforcement agency

[5] Fire department

[6] EMS

[8] Other (Specify __________________)

[A] Health department/health agency

[B] Environmental agency/EPA response team

[C] 3^rd Party Clean-up Contractor

[D] Specialized multiagency teams

[E] Department of works/utilities/transportation (includes coast guard)

[F] State, County or local Emergency managers/coordinators/planning committees

[G] Hospital

[H] Poison Center

[J] ACE team

COMMENTS/SYNOPSIS

35. Are there any comments on the data collection form?

1 = Yes

2 = No

(If yes, enter the question number and comment in the comments field.)

______________________________________________________________________________

36. Enter a synopsis of the event with pertinent information

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

24