NRC Form 361S Part 53 Plant Event Notification Worksheet

of

Page
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 Infocollects.Resource@nrc.gov, 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 - hoo.hoc@nrc.gov
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)