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APPENDIX F: Federal-lead UST Corrective Action Accident Report Format OSWER Directive 9360.0-16a Guidance for Conducting Federal-Lead Underground Storage Tank Corrective Actions July 25, 1988

OSWER DIRECTIVE 9360.0-16A

Date of Report:______________

Prepared By:________________

Preparer's Phone #:___________

1. Date and Time of Incident:

2. Site name and Location:

3. OSC:

4. Description of Incident:

5. Factors Leading Up to Incident:

6. Site Work Related to Incident (OSC Orders, TAT oversight, Foreman's Orders):

7. Weather Conditions During Incident (Temperature, Humidity, Wind Direction and Speed, Precipitation):

8a. Injuries (Person, Role of Person On Site, Description of Injury):

8b. Exposure (Person Exposed, Substances Involved, Type of Exposure - Inhalation, Ingestion, Dermal):

8c. Medical Treatment (Paramedic, Physician, Hospital, Length of Stay, Estimated Cost):

9. Property Damage (Owner, Location, Description of Damages, Estimated Cost):

10a. Other Persons on Site:

10b. Other Person's Roles/Activities On Site on Day of Incident:


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