Form Dot F 5800 1 PDF Details

Engaging with the DOT F 5800.1 form unveils a crucial process set forth by the U.S. Department of Transportation, Pipeline, and Hazardous Materials Safety Administration, designed to gather comprehensive data on incidents involving hazardous materials. This mandatory form, blessed with the approval from the Office of Management and Budget under number 2137-0039, serves as a testament to the government's commitment to monitoring and enhancing the safety of transporting dangerous goods. Spanning a variety of detailed sections, the form insists on a factual recount of the incident, including the type, general information, packaging details, consequences, and emergency response efforts, not forgetting the suggestions for preventing similar events. Submission instructions are clear, requesting additional sheets if the space provided falls short, ensuring that every incident is reported with utmost precision to the Information Systems Manager at the specified address. The complexity of hazardous material transportation is acknowledged through meticulous documentation requirements, from the initial report to additional follow-ups, aiming to fortify the safety parameters and mitigate risks associated with such shipments. By obligating carriers, shippers, and other involved parties to disclose comprehensive details about any incident, this form acts as a cornerstone in the pursuit of a safer transportation environment for hazardous materials.

QuestionAnswer
Form NameForm Dot F 5800 1
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdot form f 5800 1, f dot form, dot f hazardous online, dot f form

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U.S.฀Department฀of฀Transportation

Pipeline฀and฀Hazardous฀Materials

Safety฀Administration

Hazardous฀Materials

Incident฀Report

Form Approval OMB No. 2137-0039

According฀to฀the฀Paperwork฀Reduction฀Act฀of฀1995,฀no฀persons฀are฀required฀to฀respond฀to฀a฀collection฀of฀information฀unless฀it฀displays฀a valid฀OMB฀control฀number.฀The฀valid฀OMB฀control฀number฀for฀this฀information฀collection฀is฀2137-0039.฀The฀filling฀out฀of฀this฀information฀is mandatory฀and฀will฀take฀96฀minutes฀to฀complete

INSTRUCTIONS: Submit฀this฀report฀to฀the฀Information฀Systems฀Manager,฀U.S.฀Department฀of฀Transportation,฀Pipeline฀and฀Hazardous฀Materials

Safety฀Administration,฀Offi฀ce฀of฀Hazardous฀Materials฀Safety,฀DHM-63,฀Washington,฀D.C.฀20590-0001.฀If฀space฀provided฀for฀any฀item฀is฀inadequate,

use฀a฀seperate฀sheet฀of฀paper,฀identifying฀the฀entry฀number฀being฀completed.฀Copies฀of฀this฀form฀and฀instructions฀can฀be฀obtained฀from฀the

Offi฀ce฀of฀Hazardous฀Materials฀Website฀at฀http://hazmat.dot.gov.฀If฀you฀have฀any฀questions,฀you฀can฀contact฀the฀Hazardous฀Materials฀Information

Center฀at฀1-800-HMR-4922฀(1-800-467-4922)฀or฀online฀at฀http://hazmat.dot.gov.

PART฀I฀-฀REPORT฀TYPE

1.This is to report:

2.Indicate whether this is:

A)฀A hazardous material incident

B) An undeclared shipment with no release

C)A specification cargo tank 1,000 gallons or greater containing any hazardous materials that

(1)received structural damage to the lading retention system or damage that requires repair to a system intended to protect the lading retention system and (2) did not have a release.

An initial report

A supplemental (follow-up) report

Additional Pages

PART฀II฀-฀GENERAL฀INCIDENT฀INFORMATION

3. Date of Incident:

 

4. Time of Incident (use 24-hour time):

5.Enter National Response Center Report Number (if applicable):

6.If you submitted a report to another Federal DOT agency, enter the agency and report number:

7. Location of Incident:

City:

 

 

 

County:

 

 

 

State:

 

 

 

ZIP Code (if known):

 

Street Address/Mile Marker/Yardname/Airport/Body of Water/River Mile

 

 

 

 

 

 

 

 

 

8. Mode of Transportation

Air

Highway

 

Rail

 

 

Water

9. Transportation Phase

 

 

 

 

In Transit

Loading

 

Unloading

 

 

In Transit Storage

10.

Carrier/Reporter

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

Federal DOT ID Number

 

 

 

Hazmat Registration Number

11.

Shipper/Offeror

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

Waybill/Shipping Paper

 

 

 

Hazmat Registration Number

12.

Origin

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if different from

City

 

 

 

 

 

 

 

 

State

ZIP Code

 

shipper address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Destination

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

14.Proper Shipping Name of Hazardous Material:

15.Technical/Trade Name:

16.

Hazardous Class/

17. Identification

 

18. Packing

19. Quantity

 

Division:

 

Number:

 

 

 

Group:

 

Released:

 

 

 

 

(E.g. UN2764, NA 2020)

 

 

(if applicable)

(Include Measurement Units)

20. Was the material shipped as a hazardous waste?

Yes

No

If yes, provide the EPA Manifest Number:

 

21.

Is this a Toxic by Inhalation (TIH) material?

Yes

No

If yes, provide the Hazard Zone:

 

22.

Was the material shipped under an Exemption, Approval, or Competent Authority Certificate?

Yes

No

 

If yes, provide the Exemption, Approval, or CA number:

 

 

 

23.

Was this an undeclared hazardous materials shipment?

Yes

No

Form DOT F 5800.1 (01-2004)

Page 1

Reproduction of this form is permitted

PART฀III฀-฀PACKAGING฀INFORMATION

24.Check Packaging Type (check only one - if more than one, list type of packaging, copy Part III, and complete for each type:

Non-bulk

IBC

Cargo tank Motor Vehicle (CTMV)

Tank Car

Cylinder

RAM

Portable Tank

Other

 

25.See instructions and enter the appropriate failure codes found at the end of the instructions. Be sure to enter the codes from the list that corresponds to the particular packaging type checked above. Enter the number of codes as appropriate to describe the incident. Enter the most important failure point in line 1. If there are more than two failure points, provide in this format in part VI.

1.

What Failed:

 

 

 

 

 

How Failed:

 

 

 

 

 

Causes of Failure:

2.

What Failed:

 

 

 

 

 

How Failed:

 

 

 

 

 

Causes of Failure:

26a. Provide the packaging identification markings, if available.

Identification Markings:

(Examples: 1A1/Y1.4/150/92/USA/RB/93/RL, UN31H1/Y0493/USA/M9339/10800/1200, DOT - 105A - 100W (RAIL), DOT 406 (HIGHWAY), DOT 51, DOT 3-A)

26b. For Non-bulk, IBC, or non-specification packaging, if identification markings are incomplete or unavailable, see instructions and

complete the following:

Single฀Package฀or฀Outer฀Packaging:

 

Single฀Package฀or฀Inner฀Packaging฀(if฀any):

Packaging Type:

 

 

Packaging Type:

 

Material of Construction:

 

 

Material of Construction:

 

Head Type (Drums only):

Removable

Non - Removable

27.Describe the package capacity and the quantity:

Single฀Package฀or฀Outer฀Packaging:

Single฀Package฀or฀Inner฀Packaging฀(if฀any):

Package Capacity:

 

Package Capacity:

 

Amount in Package:

 

Amount in Package:

 

Number in Shipment:

 

Number in Shipment:

 

Number Failed:

 

Number Failed:

 

28.Provide packaging construction and test information, as appropriate:

Manufacturer:

 

Manufacture Date:

 

Serial Number:

 

Last Test Date:

 

Material of Construction:

 

(if Tank Car, CTMV, Portable Tank, or Cylinder)

Design Pressure:

 

(if Tank Car, CTMV, Portable Tank)

Shell Thickness:

 

(if Tank Car, CTMV, Portable Tank)

Head Thickness:

 

(if Tank Car, CTMV)

Service Pressure:

 

(if Cylinder)

If valve or device failed:

 

 

 

 

Type:

 

Manufacturer:

 

Model:

 

 

 

(if present and legible)

(if present and legible)

29.If the packaging is for Radioactive Materials, complete the following:

Packaging Category:

Type A

Type B

Type C

 

Excepted

Industrial

Packaging Certification:

Self Certified

U.S. Certification

Certification Number

 

 

Nuclide(s) Present:

 

 

Transport Index:

 

 

 

 

 

Activity:

 

Critical Safety Index:

 

 

 

 

 

 

 

 

 

 

 

 

 

Form DOT F 5800.1 (01-2004)

 

Page 2

 

 

 

Reproduction of this form is permitted
PART฀IV฀-฀CONSEQUENCES

30. Result of Incident (check all that apply):

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 #

 

 

Police Report #

 

 

 

In-house cleanup

Other Cleanup

32. Damages:

Was the total damage cost more than $500?

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:

$

 

 

$

 

 

 

$

 

 

$

 

 

$

 

 

(See damage definitions in the instructions)

33a. Did the hazardous material cause or contribute to a human fatality?

If yes, enter the number of fatalities resulting from the hazardous material:

Fatalities:EmployeesResponders

33b. Were there human fatalities that did not result from the hazardous material? 34. Did the hazardous material cause or contribute to personal injury?

If yes, enter the number of injuries resulting from the hazardous material:

Hospitalized (Admitted Only):

Employees

 

Responders

Non-Hospitalized:

Employees

 

Responders

Yes

No

 

 

 

 

 

General Public

 

Yes

No

If yes, how many?

Yes

No

 

 

 

 

 

General Public

 

 

 

General Public

 

 

(e.g.: On site first aid or Emergency Room observation and release)

 

 

 

 

 

 

 

 

 

35.

Did the hazardous material cause or contribute to an evacuation?

Yes

No

 

 

 

 

 

 

 

If yes, provide the following information:

 

 

 

 

 

 

 

 

 

 

 

 

 

Total number of general public evacuated

 

Total number of employees evacuated

 

 

 

Total Evacuated

 

 

 

Duration of the evacuation

 

(hours)

 

 

 

If yes, how many?

 

(hours)

 

 

 

 

 

 

36.

Was a major transportation artery or facility closed?

Yes

No

 

37.

Was the material involved in a crash or derailment?

Yes

No

 

 

 

 

 

 

 

If yes, provide the following information:

Estimated speed (mph):

 

Weather conditions:

 

 

 

 

 

 

 

Vehicle overturn?

Yes

No

 

 

 

 

 

 

 

 

 

 

Vehicle left roadway/track?

Yes

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

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

PART฀VI฀-฀DESCRIPTION฀OF฀EVENTS฀&฀PACKAGE฀FAILURE

Describe the sequence of events that led to the incident and the actions taken at the time it was discovered. Describe the package failure, including the size and location of holes, cracks, etc. Photographs and diagrams should be submitted if needed for clarification. Estimate the duration of the release, if possible. Describe what was done to mitigate the effects of the release. Continue on additional sheets if

necessary.

PART฀VII฀-฀RECOMMENDATIONS/ACTIONS฀TAKEN฀TO฀PREVENT฀RECURRENCE

Where you are able to do so, suggest or describe changes (such as additional training, use of better packaging, or improved operating procedures) to help prevent recurrence. Provide recommendations for improvement to hazardous materials transportation beyond the control of your individual company. Continue on additional sheets if necessary.

PART฀VIII-฀CONTACT฀INFORMATION

Contact’s Name (Type or Print):

 

 

Telephone Number: ( )

Contact’s Title:

 

 

 

 

 

Fax Number: ( )

 

 

 

 

 

 

 

 

 

 

 

 

Business Name and Address:

 

 

Hazmat Registration Number (if not already provided):

 

 

 

 

 

 

 

 

 

 

 

E-mail Address:

 

 

 

 

Date:

Preparer is:

Carrier

Shipper

Facility

 

 

Other

 

Form DOT F 5800.1 (01-2004)

Page 4

Reproduction of this form is permitted

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The right way to fill in f dot form step 1

2. Soon after completing the last section, go on to the subsequent stage and fill out the essential details in all these fields - Origin if different from shipper, Destination, Street, City, Street, City, Proper Shipping Name of Hazardous, Hazmat Registration Number, State, ZIP Code, State, ZIP Code, TechnicalTrade Name, Hazardous Class Division, and Identifi cation Number Eg UN NA.

Completing segment 2 of f dot form

3. This 3rd step is usually fairly straightforward, Check Packaging Type check only, Nonbulk, Cylinder, IBC, RAM, Cargo tank Motor Vehicle CTMV, Portable Tank, Tank Car, Other, See instructions and enter the, What Failed, What Failed, How Failed, How Failed, and Causes of Failure - all of these form fields must be filled in here.

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4. To move ahead, this step involves typing in several form blanks. Examples include Package Capacity, Amount in Package, Number in Shipment, Number Failed, Package Capacity, Amount in Package, Number in Shipment, Number Failed, Provide packaging construction and, Manufacturer, Serial Number, Material of Construction, Design Pressure, Shell Thickness, and Head Thickness, which you'll find crucial to continuing with this particular process.

Provide packaging construction and, Shell Thickness, and Serial Number in f dot form

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5. As you draw near to the final parts of this form, you will find a few more points to complete. In particular, If the packaging is for, Packaging Category, Type A, Type B, Type C, Excepted, Industrial, Packaging Certifi cation, Self Certifi ed, US Certifi cation, Certifi cation Number, Nuclides Present, Activity, Transport Index, and Critical Safety Index should be filled out.

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