Form NRC Form 361 NRC Form 361 Reactor Plant Event Notification Worksheet

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NRC FORM 361
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

REACTOR PLANT EVENT
NOTIFICATION WORKSHEET

APPROVED BY OMB: NO. 3150-XXXX

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this voluntary collection request: 30 minutes. The information
provided will be used for evaluation of licensee event description, facility status and for input to the public website.
Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by e-mail to [email protected], and to the Desk Officer,
Office of Information and Regulatory Affairs, NEOB-10202, (3150-XXXX), Office of Management and Budget,
Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB
control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information
collection.

EN #

NRC OPERATIONS TELEPHONE NUMBERS: PRIMARY - 301-816-5100 or 800-532-3469ǂ, BACKUPS - [1st ] 301-951-0550 or 800-449-3694ǂ,
[2nd] 301-415-0550 and [3rd] 301-415-0553. ǂLicensees who maintain their own ETS are provided these telephone numbers.
FAX - 301-816-5151, EMAIL - [email protected]
Notification Time

Facility or Organization

Unit

Event Time & Zone

Event Date

Power/Mode (At Time of Event)

EVENT CLASSIFICATION
GENERAL EMERGENCY

Name of Caller/Title

Power/Mode (At Time of Notification)

1-HR. NON-EMERGENCY 10 CFR 50.72(b)(1)

(v)(A)

Safe S/D Capability

AINA

ADEV

(v)(B)

RHR Capability

AINB

SIT/AAEC 4-HR. NON-EMERGENCY 10 CFR 50.72(b)(2)

(v)(C)

Control of Rad Release

AINC
AIND

GEN/AAEC

SITE AREA EMERGENCY

Call Back #

TS Deviation

ALERT

ALE/AAEC

(i)

TS Required S/D

ASHU

(v)(D)

Accident Mitigation

UNUSUAL EVENT

UNU/AAEC

(iv)(A) ECCS Discharge to RCS

ACCS

(xii)

Offsite Medical

AMED

(iv)(B) RPS Actuation (scram)

ARPS

(xiii)

Loss Comm/Asmt/Response

ACOM

(xi)

APRE

60-DAY OPTIONAL 10 CFR 50.73(a)(1)

50.72 NON-EMERGENCY

(see next columns)

PHYSICAL SECURITY (73.71)

DDDD

MATERIAL/EXPOSURE

B???? 8-HR. NON-EMERGENCY 10 CFR 50.72(b)(3)

FITNESS FOR DUTY
OTHER UNSPECIFIED REQMT.

Offsite Notification

Invalid Specified System Actuation

AINV

OTHER UNSPECIFIED REQUIREMENT (IDENTIFY)

HFIT

(ii)(A)

Degraded Condition

ADEG

(see last column)

(ii)(B)

Unanalyzed Condition

AUNA

NONR

AESF

NONR

INFORMATION ONLY

HFIT

(iv)(A) Specified System Actuation

Event Description (Include: Systems affected, actuations and their initiating signals, causes, effect of event on plant, actions taken or planned, etc.) (Continue on Page 2)

NOTIFICATIONS
NRC RESIDENT
STATE(s)
LOCAL

YES

NO

WILL
BE

Anything Unusual or not understood?

Yes (Explain above)

No

Did all systems function as required?

Yes

No (Explain above)

OTHER GOV AGENCIES

Mode of operations until corrected (if applicable)

MEDIA/PRESS RELEASE

Additional Information continued on next page?

NRC FORM 361 (MM-YYYY)

Yes

No
Continued on next page

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NRC FORM 361
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U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

REACTOR PLANT EVENT NOTIFICATION WORKSHEET (Continued)

EN #

RADIOLOGICAL RELEASES: CHECK OR FILL IN APPLICABLE ITEMS (specific details/explanations should be covered in event description)
Liquid Release

Gaseous Release

Unplanned Release

Planned Release

Ongoing

Terminated

Monitored

Unmonitored

Offsite Release

T.S. Exceeded

RM Alarms

Areas Evacuated

Personnel Exposed or Contaminated

Offsite Protection Actions Recommended

Release Rate (Ci/sec)

% T.S. Limit

HOO Guide

*State release path in description

Total Activity (Ci)

% T.S. Limit

HOO Guide

Noble Gas

0.1 Ci/sec

1000 Ci

Iodine

10 μCi/sec

0.01 Ci

Particulate

1 μCi/sec

1 mCi

Liquid (excluding
tritium and dissolved
noble gas)

10 μCi/min

0.1 Ci

Liquid (tritium)

0.2 Ci/min

5 Ci

TOTAL
Plant Stack

Condenser/Air Ejector

Main Steam Line

SG Blowdown

Other

RAD Monitor
Readings
Alarm Setpoints
% T.S. Limit (If
applicable)
RCS OR SG TUBE LEAKS: CHECK OR FILL IN APPLICABLE ITEMS: (specific details/explanations should be covered in event description)
Location of the Leak (e.g., SG #, valve, pipe, etc.)
Leak Rate

Units: gpm/gpd

Leak Start Date

Time

T. S. Limits

Coolant Activity
and Units:

Sudden or Long-Term Development

Primary

Secondary

List of Safety Related Equipment not Operational

Event Description (Include: Systems affected, actuations and their initiating signals, causes, effect of event on plant, actions taken or planned, etc.) (Continued from Page 1)

NRC FORM 361 (MM-YYYY)