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::  RAILROAD REPORT (HTML)  ::

NOTE:  These Forms should NOT be submitted to the NRC via fax or mail. They were created for use in Training

and/or Response Plans, or to use as a guide when contacting the NRC.   

Fields displayed in RED and with an * are mandatory entries.  Please fill out the form as completely as possible.  

*Is this a DRILL Report ?       YES  NO

*E-Mail Address:

REPORTING PARTY

SUSPECTED RESPONSIBLE PARTY

*Phone 1:      Type:

*Last Name: 

*Last Name: 

First Name: 

First Name:  

Phone 1:       Type:

Phone 2:      Type:

Phone 2:       Type:

Phone 3:      Type:

Phone 3:       Type:

Company:   

Company:   

*Org Type:    

*Org Type:    

Address:    

Address:     

                   

                   

City:            

City:             

*State:          

*State:          

ZIP:             

ZIP:             

Are you calling on behalf of responsible party:

Yes  No

Are you or your company responsible for Material released:  

Yes  No

INCIDENT DESCRIPTION

*Description of Incident: 

*Incident Date:    *Time:         *Occurred/Discovered/Planned: 

Type of Incident:  RAILROAD

*Incident Cause: 

INCIDENT LOCATION

*Location Description:

*Address Location:

*State:     

*County:   

ZIP:       

Nearest City:        Distance from Nearest City:               Units:  

Direction:      Range:    Section:    Township: 

Latitude:     Degrees:     Minutes:     Seconds:         Quadrant:   

Longitude:  Degrees:    Minutes:      Seconds:          Quadrant:   

RAILROAD  DETAILS

Brake Failure Incident ?:  Yes  No Unknown

Subdivision:        Mile Post: 

Transit Service Restored:        Passenger Train Route:  Yes  No Unknown

Expect Passenger Train Delay:   Yes  No Unknown

How does the Carrier plan to handle the passengers:

GRADE CROSSING DETAILS

Grade Crossing Incident ?  Yes  No Unknown

Type of Vehicle Involved: 

Crossing Device:              

Device Operational ?   Yes  No

DOT Crossing Number: 

Was Federal Post Accident 219.201 Subpart C Testing Performed?  Yes  No  Unknown  

NUMBER OF JOB TITLES TESTED

Conductors: 

Yard Foremen:  

Engineers:    

RCL Operators: 

Trainmen:     

Brakemen:         

Titles and Numbers Unknown: 

TRAIN  DETAILS

*Railroad Name:      *Train Type:      *Unit Number: 

Number of Locomotives:                Number of Cars:          Number of Derailed:  

 Train Speed:                                   Track Speed:                 Train Direction:        

 

Railroad Name:      Train Type:      Unit Number: 

Number of Locomotives:                 Number of Cars:          Number of Derailed:  

Train Speed:                                    Track Speed:                 Train Direction:        

 Suspected Non-Compliance with DOT Regulations ?:  Yes  No

DERAILED DETAILS

*Car Number:    Position:        Car    Locomotive      *Cargo/Contents: 

Car Number:    Position:        Car    Locomotive      Cargo/Contents: 

ALLISION DETAILS

Allision Involved:  Yes     No    Unkown

Structure Type: 

Structure Name: 

Structure Operational  Yes    No  Unknown

MATERIAL INVOLVED

MATERIAL #1
*Material:       CHRIS Code:          CAS Code: 

*Amount Released:    *Units:    Amount in Water:    Units: 

MATERIAL #2
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #3
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #4
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #5
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL IN WATER INFORMATION

Body of Water Affected:       Offshore:  Yes  No       River Mile Marker:  

Tributary of:                   Water Supply Contaminated:  Yes   No  Unknown 

 Water Temperature:      Units:   

Wave Condition:     Speed:    Units:      Direction:

SHEEN INFORMATION

Sheen Length:         Units:        Sheen Width:     Units:  

Color:                               Direction of Movement: 

Odor Description: 

 

IMPACT INFORMATION

Medium Affected:        Detailed Medium Information:

Fire:

Yes  No  Unknown

Fire Extinguished:  Yes  No  Unknown

Injuries:

Yes  No  Unknown

Number of Injuries:           
Number to Hospital:       
Rail Employee Injuries: 
Rail Passenger Injuries:

Fatalities:

Yes  No  Unknown

Number of Fatalities:     
Employee Fatalities:      
Passenger Fatalities:    
Vehicle Fatalities:         

Evacuations:

Yes  No  Unknown

Number Evacuated:      
Radius/Area in Miles:   
Who was Evacuated:    

Damages:

Yes  No  Unknown

Damage in Dollars:       

Road Closed:

Yes  No  Unknown

Road:                            
Major Artery:                    Yes    No
Hours Closed:              
Direction of Closure:     

Track Closed:

Passengers Transferred:

Yes  No  Unknown

Yes  No  Unknown

Track:                         
Hours Closed:            
Direction of Closure:  

Air Corridor Closed:

Yes  No  Unknown

Air Corridor:                
Hours Closed:             

Waterway Closed:

Yes  No  Unknown

Waterway:                   
Hours Closed:             

Environmental Impact:

Yes  No Unknown

Type of Impact:      

 

Media Interest:             

WEATHER INFORMATION

Weather Conditions:                       Air Temperature:            

Wind Speed:           Unit:          Wind Direction:    

REMEDIAL ACTION INFORMATION

Remedial Action Taken:  

Release Secured:    Yes  No  Unknown      Release Duration:      Unit:  

Rate of Release:              Unit:               Per:   

ADDITIONAL AGENCY INFORMATION

Federal Agency Notified: 

State/Local Agency Notified: 

State/Local Agency On-Scene: 

State Agency's Report Number: 

ADDITIONAL INFORMATION

Additional Information:

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