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NRC FORM 361S
(MM-DD-YYYY)
U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER
PART 53 PLANT EVENT
NOTIFICATION WORKSHEET
APPROVED BY OMB: NO. 3150-0238
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
FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by
email 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. 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
Unit
Event Time & Zone
Event Date
Power/Mode (At Time of Event)
1-HR. NON-EMERGENCY
10 CFR 53.1630(b)(1)
EVENT CLASSIFICATION
GENERAL EMERGENCY
GEN/AAEC
SIT/AAEC
SITE AREA EMERGENCY
Name of Caller/Title
TS Deviation
4-HR. NON-EMERGENCY
10 CFR 53.1630(b)(2)
Call Back #
Power/Mode (At Time of Notification)
8-HR. NON-EMERGENCY
10 CFR 53.1630(b)(3)
(i)(A) Degraded Condition
(i)(B) Unanalyzed Condition
60-DAY OPTIONAL
10 CFR 53.1640(a)(1)
Invalid Specified System Actuation
OTHER UNSPECIFIED REQUIREMENT
(IDENTIFY)
ALERT
ALE/AAEC
(i) TS Required S/D
(ii) Safety-Related (SR)
System Actuation
NONR
UNUSUAL EVENT
UNU/AAEC
(ii) RPS Actuation (scram)
(iii) Unfulfilled Safety Function
NONR
(iii) Safety-Related (SR) Standby
Cooling System Actuation
(iv) Offsite Medical
(v) Loss Comm/Asmt/Response
53.1630 NON-EMERGENCY
(see next columns)
10 CFR 73
D????
(iv) Rad Release within Plant
MATERIAL/EXPOSURE
B????
(v) Offsite Notification
HFIT
FITNESS FOR DUTY
OTHER UNSPECIFIED REQMT.
(see last column)
INFORMATION ONLY
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
YES
NRC RESIDENT
STATE(s)
LOCAL
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 361S (MM-DD-YYYY)
Yes
No
Continued on next page
Page
NRC FORM 361S
(MM-DD-YYYY)
PART 53 PLANT EVENT NOTIFICATION WORKSHEET (Continued)
of
U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER
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 361S (MM-DD-YYYY)
File Type | application/pdf |
File Modified | 2024-07-09 |
File Created | 2024-07-09 |