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PART IV - CONSEQUENCES 30. Result of Incident (check all that apply): 0 Spillage ❑ Fire ❑ Explosion ❑ Material Entered Waterway/Storm Sewer ❑ Vapor (Gas) Dispersion ❑ Environmental Damage ❑ No Release 31. Emergency Response : The following entities responded to the incident: (Check all that apply) ❑ Fire/EMS Report # N/A ❑ Police Report # N/A (] In-house cleanup ❑ Other Cleanup 32. Damages: Was the total damage cost more than $500? 0 Yes ❑ No If yes, enter the following information: If no, go to question 33. Material Loss: Carrier Damage: Property Damage: Response Cost: Remediation/Cleanup Cost: $ 10 $ 0 $ 0 $ 7,500 $ 0 (See damage definitions in the instructions) 33a. Did the hazardous material cause or contribute to a human fatality? ❑ Yes 0 No If yes, enter the number of fatalities resulting from the hazardous material: Fatalities: Employees N/A Responders N/A General Public N/A 33b. Were there human fatalities that did not result from the hazardous material? ❑ Yes 0 No If yes, how many? N/A 34. Did the hazardous material cause or contribute to personal injury? ❑ Yes 0 No If yes, enter the number of injuries resulting from the hazardous material: Hospitalized (Admitted Only): Employees N/A Responders N/A General Public N/A Non -Hospitalized: Employees N/A Responders N/A General Public N/A (e.g.: On site first aid or Emergency Room observation and release) 35. Did the hazardous material cause or contribute to an evacuation? ❑ Yes 0 No If yes, provide the following information: Total number of general public evacuated N/A Total number of employees evacuated N/A Total Evacuated N/A Duration of the evacuation N/A (hours) 36. Was a major transportation artery or facility closed? ❑ Yes 0 No If yes, how many? N/A (hours) 37. Was the material involved in a crash or derailment? ❑ Yes 0 No If yes, provide the following information: Estimated speed (mph): N/A Weather conditions: N/A Vehicle overturn? ❑ Yes 0 No Vehicle left roadway/track? ❑ Yes 0 No PART V - AIR INCIDENT INFORMATION (please refer to § 175.31 to report a discrepancy for air shipments) 38. Was the shipment on a passenger aircraft? ❑ Yes 0 No If yes, was it tendered as cargo, or as passenger baggage? ❑ Cargo ❑ Passenger baggage 39. Where did the incident occur (if unknown, check the appropriate box for the location where the incident was discovered)? ❑ Air carrier cargo facility ❑ Sort center ❑ Baggage area ❑ By surface to/from airport ❑ During flight ❑ During loading/unloading of aircraft 40. What phase(s) had the shipment already undergone prior to the incident? (Check all that apply) ❑ Shipment had not been transported ❑ Transported by air (first flight) ❑ Transport by air (subsequent flights) ❑ Initial transport by highway to cargo facility ❑ Transfer at sort center/cargo facility Form DOT F 5800.1 (01-2004) Page 3 Reproduction of this form is permitted