ADEM Incident Report Click here for a print-friendly version of this form Name of Person Requesting:   Organization/Agency:   Contact Number:

Incident Type: Accident River Animal Disease Emergency Aviation Security Bomb Threat Downed Aircraft Civilian Downed Aircraft Military Drowning Earthquake Emergency Locator Transmission Fire Forest Fire Structure Flood Impact Hazmat Air Hazmat Disposal Site Hazmat Fixed Facility Hazmat Highway Hazmat Landfill Hazmat MFG Hazmat Misc Hazmat Pipeline Hazmat Rail Hazmat Refinery Hazmat River Hazmat Storage Hazmat Stream Hazmat Waste Highway Accident Ice Storm Impact Lost Person Miscellaneous Impact Nuclear Non-Fixed Nuclear Fixed PBA 1/2 PBA 3 PBA 4 Pipeline Accident RADMAT Movement Terrorism Event Thunderstorm Impact Tornado Impact Train Accident Utility Failure (Power) Water Shortage
Has incident been previously reported? No  Yes   Type in the incident number if known:
Incident Location: County: Arkansas Ashley Baxter Benton Boone Bradley Calhoun Carroll Chicot Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Desha Drew Faulkner Franklin Fulton Garland Grant Greene Hempstead Hot Spring Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Lee Lincoln Little River Little Rock Logan Lonoke Madison Marion Miller Mississippi Monroe Montgomery Nevada Newton North Little Rock Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saline Scott Searcy Sebastian Sevier Sharp St. Francis Stone Union Van Buren Washington White Woodruff Yell City: Exact Location:	Roadway Blocked? No  Yes   Highway/Street Name:
Date Occurred:	Time Occurred:
Hazardous Material(s):	Quantity:
Waterways Affected? No  Yes   Name/Location of Affected waterways: Is affected waterway a public water source? No  Yes   Is wildlife endangered/threatened? No  Yes
Vehicle Type: Aircraft - Civilian Aircraft - Military Bus - Private Carrier Bus - Public Transport Commercial Truck Passenger Vehicle - Car Passenger Vehicle - Truck Train Tractor/Trailer
Specify Driver Injury:	Minor Injury - No Transport Major Injury Transported to Hospital Fatality
Owner Name: Address: Contact #: Has the owner been notified? No  Yes   Name of environmental cleaup company: Address: Contact #:
Evacuation
Has the incident area been evacuated? No  Yes   Number of people evacuated: Description of evacuated area: Shelter Open? No  Yes   Shelter Location: Number of people sheltered: Red Cross notified? No  Yes
Emergency Response
Arkansas State Police:	NotifiedOn the Scene
Arkansas Highway Police:	NotifiedOn the Scene
ADEM:	NotifiedOn the Scene
County Sheriff's Office:	NotifiedOn the Scene
City Police Department:	NotifiedOn the Scene
ADEQ:	NotifiedOn the Scene
State Health:	NotifiedOn the Scene
Arkansas Game and Fish Commission:	NotifiedOn the Scene
Ambulance/EMT:	NotifiedOn the Scene
Highway Department:	NotifiedOn the Scene
Fire/Rescue:	NotifiedOn the Scene
Environmental Cleaup Company:	NotifiedOn the Scene
Company Representative/Responsible Party:	NotifiedOn the Scene
Has National Response Center been notified?	NoYes
Name of Environmental Cleanup Company:
Name of company representative/responsible party:
Assistance Requested:
Brief Description/Comments: