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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)
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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)
File Type | application/pdf |
File Modified | 2022-09-08 |
File Created | 2022-07-12 |