Chemical Spill Site Assessment Form

Site Information

Site Name Location Date Assessor Name

Spill Details

Chemical(s) Involved Estimated Quantity Released Physical State Solid Liquid Gas Suspected Cause How was the spill discovered?

Exposure & Impact

Personnel Exposed Any injuries or symptoms reported? Environmental Impact Observed

Containment & Clean-Up

Immediate Actions Taken Personal Protective Equipment (PPE) Used Waste Disposal Method

Comments & Recommendations

Additional Comments / Recommendations