General Information

Date of Incident: 

[Month Day, Year]

Time of Incident: 

Location of Incident:

Employee Name:

ID Number:

Department:

Job Title:

Incident Details

Action Taken:

Chlorine Gas

Quantity Involved: 

Description of the Incident:

Immediate Actions Taken

Action Taken 1:

Emergency alarm activated

Action Taken 2:

Action Taken 3:

Potential Hazards Identified

Hazard Type:

Air contamination

Severity Level:

Potential Impact:

Witnesses

Witness 1 Name:

[Name]

Contact Information:

Statement Summary:

Witness 2 Name:

Contact Information:

Statement Summary:

Corrective Actions Recommended

Suggested Action:

Replace faulty valve

Expected Outcome:

Implementation Deadline:

Investigator's Notes

The incident was contained effectively with no injuries reported. The valve's failure appears to be due to wear and tear. Regular maintenance checks might have prevented this incident.