REACTOR PLANT EVENT NOTIFICATION WORKSHEET

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NRC FORM 361
(MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0238

REACTOR PLANT EVENT
NOTIFICATION WORKSHEET

of

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evaluation of licensee event description, facility status and for input to the public website. Send comments regarding burden estimate to the
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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

Name of Caller/Title

Event Time & Zone

Event Date

Power/Mode (At Time of Event)

Call Back #

Power/Mode (At Time of Notification)

1-HR. NON-EMERGENCY
10 CFR 50.72(b)(1)

EVENT CLASSIFICATION
GENERAL EMERGENCY

Safe S/D Capability

AINA

(v)(B)

RHR Capability

AINB

(v)(C)

Control of Rad Release

AINC

GEN/AAEC

TS Deviation

SITE AREA EMERGENCY

SIT/AAEC

4-HR. NON-EMERGENCY
10 CFR 50.72(b)(2)

ALERT

ALE/AAEC

(i)

TS Required S/D

ASHU

(v)(D)

Accident Mitigation

AIND

UNUSUAL EVENT

UNU/AAEC

(iv)(A) ECCS Discharge to RCS

ACCS

(xii)

Offsite Medical

AMED

(iv)(B) RPS Actuation (scram)

ARPS

(xiii)

Loss Comm/Asmt/Response

ACOM

50.72 NON-EMERGENCY

(see next columns)

10 CFR 20 RAD MATERIAL/EXPOSURE
10 CFR 21 DEFECT/NONCOMPLIANCE

(xi)

HFIT

10 CFR 73 SECURITY EVENT
INFORMATION ONLY

NNF

APRE

60-DAY OPTIONAL
10 CFR 50.73(a)(1)

OTHER UNSPECIFIED REQUIREMENT
(IDENTIFY)

8-HR. NON-EMERGENCY
10 CFR 50.72(b)(3)

CCCC

10 CFR 26 FITNESS FOR DUTY

Offsite Notification

ADEV

(v)(A)

Invalid Specified System Actuation

AINV

(ii)(A)

Degraded Condition

ADEG

(ii)(B)

Unanalyzed Condition

AUNA

NONR

(iv)(A) Specified System Actuation

AESF

NONR

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 361 (MM-DD-YYYY)

Yes

No

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NRC FORM 361
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U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

REACTOR PLANT EVENT NOTIFICATION WORKSHEET (Continued)

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 361 (MM-DD-YYYY)