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APPENDIX 1 <br />INFORMATION CHECKLIST <br />INCIDENT INFORMATION FORM <br />CALLER. <br />INFORMATION <br />Date Time of Report <br />Name/Title <br />Agency <br />LOCATION <br />MATERIALS <br />INVOLVED <br />DESCRIPTION <br />OF INCIDENT <br />Call back number <br />Town/City <br />Highway/Street <br />Locator (Nearby landmark) <br />Chemical Name(s) <br />Trade Name (s) <br />Placard/Label Identification/DOT Number(s) <br />Quantity involved <br />Quantity Release <br />Material characteristics (solid, liquid, vapor, other} <br />Type of incident <br />Injuries/Fatalitiesl0bserved ill effects <br />Area and/or waterbody endangered <br />Personnel on scene <br />Actions initiated <br />Time <br />N-10 <br />