Form 366A License Event Report

NRC FORM 366A

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

LICENSEE EVENT REPORT (LER)
CONTINUATION SHEET
(See NUREG-1022, R.3 for instruction and guidance for completing this form
http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1022/r3/)
1. FACILITY NAME

APPROVED BY OMB: NO. 3150-0104

Estimated burden per response to comply with this mandatory collection request: 80 hours. Reported
lessons learned are incorporated into the licensing process and fed back to industry. 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, (3150-0104), 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.

2. DOCKET NUMBER

05000-

EXPIRES: (MM/DD/YYYY)

3. LER NUMBER
SEQUENTIAL
NUMBER

YEAR

-

REV
NO.

-

NARRATIVE

NRC FORM 366A (MM-YYYY)

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