NRC Form 361A FUEL CYCLE AND MATERIALS EVENT NOTIFICATION WORKSHEET

of

Page
NRC FORM 361A
(07-13-2022)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

FUEL CYCLE AND MATERIALS
EVENT NOTIFICATION
WORKSHEET

APPROVED BY OMB: NO. 3150-0238

EXPIRES: 10/31/2022

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 FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington,
DC 20555-0001, or by e-mail to [email protected], and the OMB reviewer at: OMB Office of Information and
Regulatory Affairs, (3150-0238), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC
20503; e-mail: [email protected]. The NRC may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control
number.

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

Event Time & Zone

Event Date

License #

Name of Caller/Title

Location of Event (Include County and State)

EVENT CLASSIFICATIONS

EVENT TYPES

Call Back #

Portion of Plant Affected (If applicable)

INCIDENT REPORTS (30.50, 40.60, 70.50)
(a)

FUEL CYCLE

SITE AREA EMERGENCY

MEDICAL / ACADEMIC

ALERT

TRANSPORTATION

NOTIFICATION OF UNUSUAL EVENT*

WASTE MANAGEMENT

21.21

DEFECT / NONCOMPLIANCE

INCIDENT REPORT

INDUSTRIAL/ COMMERCIAL

26.791

FITNESS FOR DUTY

(b)(4) FIRE / EXPLOSION

TRANSPORATION EVENT

FOREIGN EVENT

35.3045

MEDICAL EVENT

70.52 CRITICALITY / SNM LOST

PHYSICAL SECURITY

OTHER (Specify)

36.83

IRRADIATOR EVENT

70.52 ACTUAL / ATTEMPTED
THEFT

39.77

RUPTURED WELL
LOGGING SOURCE
IRRETRIEVABLE WELL
LOGGING SOURCE
TAILINGS / WASTE
DAM FAILURE

INFORMATION ONLY

STATE(s)
LOCAL
OTHER GOVERNMENT
AGENCIES

PRESS RELEASE

20.2202

ACTUAL / THREATENED
OVEREXPOSURE
ACTUAL / THREATENED
RELEASE

20.2202

40.26

*ONLY UNDER OLD 1981 ORDER

NRC REGION

LOSS / THEFT

39.77

OTHER (Specify)

NOTIFICATIONS

20.2201

PROTECTIVE ACTION
PREVENTED
(b)(1) UNPLANNED
CONTAMINATION
(b)(2) SAFETY EQUIPMENT
FAILURE
(b)(3) MEDICAL TREATMENT
WITH CONTAMINATION

GENERAL EMERGENCY*

YES

NO

WILL
BE

APPENDIX A, 1-Hour
APPENDIX A, 24-Hour
CONCURRENT REPORT

Anything Unusual or not understood?

Yes (Explain below)

No

Did all systems function as required?

Yes

No (Explain below)

Additional Information on page 2?

Yes

No

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)

NRC FORM 361A (07-13-2022)

Continued on next page

of

Page
NRC FORM 361A
(07-13-2022)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

FUEL CYCLE AND MATERIALS
EVENT NOTIFICATION WORKSHEET (Continued)

EN #

RADIOLOGICAL / CHEMICAL RELEASES: CHECK OR FILL IN APPLICABLE ITEMS
Isotope

Activity

Physical Form

Chemical Form

Stack

Liquid Effluent

Other (Specify)

Monitor Reading
Alarm Setpoint

PERSONNEL EXPOSURE / CONTAMINATION DATA

ONGOING RELEASE
TERMINATED RELEASE

Number of Personnel Exposed

Number of Personnel Contaminated

OFFSITE RELEASE

Maximum External Dose

Maximum External Level

ONSITE AREAS EVACUATED

Maximum Internal Dose

Maximum Internal Level

OFFSITE PROTECTIVE
ACTION RECOMMENDED

Critical Organ (if known)

Critical Organ (if known)

Number and Types of controls necessary under normal operating conditions

Number and Types of controls which functioned properly under upset conditions

Number and Types of controls necessary to restore a safe situation

Safety Significance of Events

Safety Equipment Status

Status of Corrective Actions

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

NRC FORM 361A (07-13-2022)