HAZMAT Incident Checklist

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Information

• Incident Name

• Start Time

  Date

• Comp. Time

  Date

Weather Information

• Present:

• Time

  Date

• Wind Direction

• Wind Speed

• Rain/Snow

• Temp. (°F)

• 1-Hour Forecast:

• Time

  Date

• Wind Direction

• Wind Speed

• Rain/Snow

• Temp. (°F)

• Long Term Forecast:

• Time

  Date

• Wind Direction

• Wind Speed

• Rain/Snow

• Temp. (°F)

Resource Information

• Name

• Assignment

Checklist

• Hot Zone

  Yes

  No

• Warm Zone

  Yes

  No

• Cold Zone

  Yes

  No

• Evacuation

  Yes

  No

• Diking

  Yes

  No

• Diversion

  Yes

  No

• Retention

  Yes

  No

• Special Equip. Needed

  Yes

  No

• Decon

  Yes

  No

• Medical

  Yes

  No

• Rehabilitation

  Yes

  No

• Research

  Yes

  No

• Product Identification

  Yes

  No

• PPE

  Yes

  No

• Resource

  Yes

  No

• Mutual Aid

  Yes

  No

• Chemical Cleanup

  Yes

  No

• Safety Briefing

  Yes

  No

• Post Critique

  Yes

  No

Agencies Contacted

• Law Enforecement

  Yes

  No

• Health Department

  Yes

  No

• ChemTrec

  Yes

  No

• EPA

  Yes

  No

• ADEQ

  Yes

  No

• Other

  Yes

  No

• Identify Other

Termination Activities

• Decontamination

  Yes

  No

• Rehabilitation

  Yes

  No

• Site Clean-up

  Yes

  No

• Medical Screening

  Yes

  No

• Exposure Reporting

  Yes

  No

• Incident Debriefing

  Yes

  No

Completion

• Notes

• Conducted by: Name and Signature

  Sign