NON-POWER REACTOR (NPR) EVENT NOTIFICATION WORKSHEET

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NRC FORM 361N
(MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

NON-POWER REACTOR (NPR)
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
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Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503. The NRC may not conduct or sponsor,
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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

Name of Caller/Title

Call Back #

Event Time & Zone

Event Date

Power/Mode Before

Power/Mode After

Reactor Type

Max Power

Max Pulse

Pulse Inserted During Event?

EVENT CLASSIFICATION

REPORTABLE CONDITION (Varies by facility TS)

GENERAL EMERGENCY

GEN/AAEC

TS Deviation

ADEV

Control of Rad Release

AINC

SITE AREA EMERGENCY

SIT/AAEC

TS Required S/D

ASHU

Accident Mitigation

AIND

ALERT

ALE/AAEC

RPS Actuation (scram)

ARPS

Offsite Medical

AMED

UNUSUAL EVENT

UNU/AAEC

Offsite Notification

APRE

Loss Comm/Asmt/Response

ACOM

10 CFR 20 RAD MATERIAL/EXPOSURE

Degraded Condition

ADEG

Invalid Specified System Actuation

AINV

10 CFR 73 SECURITY EVENT

Unanalyzed Condition

AUNA

Specified System Actuation

AESF

NONR

Safe S/D Capability

AINA

NONR

NNF

INFORMATION ONLY

OTHER UNSPECIFIED REQUIREMENT (IDENTIFY)

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

NO

WILL
BE

Anything Unusual or not understood?

Yes (Explain above)

No

Did all systems function as required?

Yes

No (Explain above)

HQ NPR STAFF
STATE(s)
LOCAL

Mode of operation until corrected (if applicable)

OTHER GOV AGENCIES

Estimate for restart date:

MEDIA/PRESS RELEASE

Additional Information continued on next page?

NRC FORM 361N (MM-DD-YYYY)

Yes

No

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

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

NON-POWER REACTOR (NPR)
EVENT NOTIFICATION WORKSHEET (Continued)

EN #

RADIOLOGICAL / CHEMICAL 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

Release Rate (Ci/sec)

Offsite Protection Actions Recommended

% 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 ACTIVITY
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 361N (MM-DD-YYYY)