NRC Form 361N Non-Power Reactor Event Notification Worksheet.

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NRC FORM 361N
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

NON-POWER REACTOR (NPR)
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

Name of Caller

Call Back #

Event Time & Zone

Event Date

Power/Mode Before

Power/Mode After

Reactor Type

Max Power

Max Pulse

Pulse Inserted During Event?

EVENT CLASSIFICATIONS
GENERAL EMERGENCY

REPORTABLE CONDITION (Varies by facility TS)
GEN/AAEC

SITE AREA EMERGENCY

SIT/AAEC

TS Deviation

ADEV

Accident Mitigation

AIND

TS Required S/D

ASHU

Offsite Medical

AMED
ACOM

ALERT

ALE/AAEC

RPS Actuation (scram)

ARPS

Loss Comm/Asmt/Response

UNUSUAL EVENT

UNU/AAEC

Offsite Notification

APRE

Invalid Specified System Actuation

SAFEGUARDS EVENT (73 App G)

Degraded Condition

ADEG

SUSPICIOUS ACTIVITY

MATERIAL/EXPOSURE

Unanalyzed Condition

AUNA

SECURITY EVENT

Specified System Actuation

AESF

Safe S/D Capability

AINA

NONR

Control of Rad Release

AINC

NONR

INFORMATION ONLY

NNF

OTHER UNSPECIFIED REQMT.

(see last column)

AINV

OTHER UNSPECIFIED REQUIREMENT (IDENTIFY)

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

NOTIFICATIONS

YES

NO

WILL
BE

Anything Unusual or not understood?

Yes (Explain above)

No

Did all systems function as required?

Yes

No (Explain above)

HQ NPR STAFF
STATE(s)
LOCAL

Mode of operation until corrected (if applicable)

OTHER GOV AGENCIES

Estimate for restart date:

MEDIA/PRESS RELEASE

Additional Information continued on next page?

NRC FORM 361N (MM-YYYY)

Yes

No
Continued on next page

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NRC FORM 361N
(MM-YYYY)

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U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

NON-POWER REACTOR (NPR)
EVENT NOTIFICATION WORKSHEET (Continued)

EN #

RADIOLOGICAL / CHEMICAL 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

Release Rate (Ci/sec)

Offsite Protection Actions Recommended

% 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 ACTIVITY
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 361N (MM-YYYY)