FUEL CYCLE AND MATERIALS EVENT NOTIFICATION WORKSHEET

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NRC FORM 361A
(MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

FUEL CYCLE AND MATERIALS
EVENT NOTIFICATION
WORKSHEET

of

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0238

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
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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

License #

Event Time & Zone

Event Date

Location of Event (Include County and State) Portion of Plant Affected (if applicable)

EVENT CLASSIFICATION

Name of Caller/Title

EVENT TYPES

GENERAL EMERGENCY*

GEN

FUEL CYCLE

SITE AREA EMERGENCY

SIT

MEDICAL/ACADEMIC

ALERT

ALE

TRANSPORTATION

UNUSUAL EVENT*

UNU

WASTE MANAGEMENT

Call Back #

INCIDENT REPORTS (30.50, 40.60, 70.50)

20.2202 ACTUAL/THREATENED
OVEREXPOSURE
20.2202 ACTUAL/THREATENED
RELEASE
21.21
DEFECT/
NONCOMPLIANCE

PROTECTIVE ACTION
PREVENTED
(b)(1) UNPLANNED
CONTAMINATION
(b)(2) SAFETY EQUIPMENT
FAILURE
(b)(3) MEDICAL TREATMENT
WITH CONTAMINATION
(b)(4) FIRE/EXPLOSION

20.2201 LOSS/THEFT

INCIDENT REPORT

INDUSTRIAL/COMMERCIAL

26.791

TRANSPORTATION EVENT

FOREIGN EVENT

35.3045 MEDICAL EVENT

70.52 CRITICALITY/SNM LOST

INFORMATION ONLY

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

10 CFR 37 CAT 1/2 MATERIAL

39.77

10 CFR 73 SECURITY EVENT

40.26

*ONLY UNDER OLD 1981 ORDER

FITNESS FOR DUTY

(a)

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

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 REGION
STATE(s)
LOCAL
OTHER GOV AGENCIES
MEDIA/PRESS RELEASE
NRC FORM 361A (MM-DD-YYYY)

NO

WILL
BE

Anything Unusual or not understood?

Yes (Explain below)

No

Did all systems function as required?

Yes

No (Explain below)

Additional Information continued on next
page?

Yes

No

Page
NRC FORM 361A
(MM-DD-YYYY)

of

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 (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 361A (MM-DD-YYYY)