NRC Form 361A NRC Form 361A, Fuel Cycle and Materials Event Notificati

of

Page
NRC FORM 361A
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
OPERATIONS CENTER

FUEL CYCLE AND MATERIALS
EVENT NOTIFICATION
WORKSHEET

APPROVED BY OMB: NO. 3150-XXXX

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 Information Services Branch (T-6 A10M), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the
Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-XXXX), Office of Management and
Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently
valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the
information collection.

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 - hoo.hoc@nrc.gov
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

INFORMATION ONLY

OTHER (Specify)

36.83

IRRADIATOR EVENT

39.77

RUPTURED WELL
LOGGING SOURCE
IRRETRIEVABLE WELL
LOGGING SOURCE
TAILINGS / WASTE
DAM FAILURE

OTHER (Specify)

20.2201

LOSS / THEFT

20.2202

ACTUAL / THREATENED
OVEREXPOSURE
ACTUAL / THREATENED
RELEASE

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

GENERAL EMERGENCY*

20.2202

39.77
40.26

*ONLY UNDER OLD 1981 ORDER
NOTIFICATIONS
NRC REGION
STATE(s)
LOCAL
OTHER GOVERNMENT
AGENCIES

PRESS RELEASE

YES

NO

WILL
BE

70.52 ACTUAL / ATTEMPTED
THEFT
CRITICALITY CONTROL 4HOUR (BULLETIN 91-01)
CRITICALITY CONTROL 24HOUR (BULLETIN 91-01)
OTHER NON-CFR
REQUIREMENT

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 (MM-YYYY)

Continued on next page

of

Page
NRC FORM 361A
(MM-YYYY)

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)

DEGRADED CRITICALITY SAFETY CONTROLS FOR ACCIDENT SCENARIO(S) (BULLETIN 91-01)
ALL CONTROLS LOST

ALL BUT SINGLE
CONTROLS LOST

DEFICIENT SAFETY
ANALYSIS

SAFETY SIGNIFICANCE
UNKNOWN

>45% MINIMUM CRITICAL MASS
PRESENT OR READILY AVAILABLE

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 (MM-YYYY)