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Category:NRC Forms (Blank)
MONTHYEARML22192A1972022-07-11011 July 2022 NRC Form 446 - Request for Approval of Official Foreign Travel by Non-Government Personnel (*Must Be Completed 30 Days Prior to Travel) ML21148A2422021-05-28028 May 2021 NRC Form 149 - Ocfo Invitational Traveler Request Form ML20339A6732021-01-12012 January 2021 NRC Form 529 - Dispute of Fees-for-Service Charges in Accordance with Title 10 of the Code of Federal Regulations (10 CFR) 170.51 ML12164A7272020-01-31031 January 2020 NRC Form 313A (Amp), Authorized Medical Physicist or Ophthalmic Physicist, Training, Experience and Preceptor Attestation (10 CFR 35.51, 35.57(a)(3), and 35.433). (01-2020) ML12164A7282020-01-31031 January 2020 NRC Form 313A (Anp), Authorized Nuclear Pharmacist Training, Experience, and Preceptor Attestation (10 CFR 35.55). (01-2020) ML12164A7332020-01-31031 January 2020 NRC Form 313A (Aud), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.100, 35.200, and 35.500) (10 CFR 35.57, 35.190, 35.290, and 35.590). (01-2020) ML12164A7362020-01-31031 January 2020 NRC Form 313A (Aus), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.400 and 35.600) (10 CFR 35.57, 35.490, 35.491, and 35.690). (01-2020) ML12164A7412020-01-31031 January 2020 NRC Form 313A (Aut), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.300)(10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396). (01-2020) ML12164A7422020-01-31031 January 2020 NRC Form 313A (Rso), Radiation Safety Officer or Associate Radiation Safety Officer Training, Experience, and Preceptor Attestation (10 CFR 35.57, 35.50). (01-2020) ML13083A1032019-10-31031 October 2019 NRC Form 361N - Non-Power Reactor (NPR) Event Notification Worksheet ML13083A0722019-09-30030 September 2019 NRC Form 313 - Application for Materials License ML13083A0192019-07-31031 July 2019 NRC Form 7 - Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(S) ML13083A1232019-07-31031 July 2019 NRC Form 396 - Certification of Medical Examination by Facility Licensee ML13083A1272019-07-31031 July 2019 NRC Form 398 - Personal Qualification Statement -- Licensee ML13083A1742019-07-31031 July 2019 NRC Form 526 - Certification of Small Entity Status for the Purposes of Annual Fees Imposed Under 10 CFR Part 171 (Effective July 16, 2019) ML13083A1762019-05-31031 May 2019 NRC Form 531 - Request for Taxpayer Identification Number ML13083A2502019-04-30030 April 2019 NRC Form 664 - General Licensee Registration ML19231A2062019-01-31031 January 2019 NRC Form 527 - Request for Information Related to Contractor Charges -- in Accordance with 10 CFR 170.51 ML16025A0332018-12-31031 December 2018 NRC Form 405F - List All Owners, Officers, Directors, and Executive Personnel (Oodep'S) ML13083A1372018-10-31031 October 2018 NRC Form 426 - Authorization to Publish a Manuscript in the NUREG Series ML13083A0942018-06-30030 June 2018 NRC Form 354 - Data Report on Spouse ML13083A1422018-05-31031 May 2018 NRC Form 445 - Request for Approval of Official Foreign Travel ML13083A1522018-04-30030 April 2018 NRC Form 483 - Registration Certificate -- in Vitro Testing with Byproduct Material Under General License ML13083A1072018-04-30030 April 2018 NRC Form 366A - Licensee Event Report (LER) Continuation Sheet ML13083A1062018-04-30030 April 2018 NRC Form 366 - Licensee Event Report (LER) ML13083A2952018-04-30030 April 2018 NRC Form 740M - Concise Note ML13083A2972018-04-30030 April 2018 NRC Form 742 - Material Balance Report ML13083A2982018-04-30030 April 2018 NRC Form 742C - Physical Inventory Listing ML13083A2962018-04-30030 April 2018 NRC Form 741 - Nuclear Material Transaction Report ML13083A2442018-02-28028 February 2018 NRC Form 653 - Transfers of Industrial Devices Report (to General Licensees) ML13083A1082018-02-28028 February 2018 NRC Form 366B - Licensee Event Report (LER) ML13114A5072017-12-31031 December 2017 NRC Form 782 - Complaint Form ML13083A3292017-12-31031 December 2017 NRC Form 781 - Sbcr Compliance Review Part a ML13083A1792017-11-30030 November 2017 NRC Form 536 - Operator Licensing Examination Data ML13083A0172017-10-31031 October 2017 NRC Form 5 - Occupational Dose Record for Monitoring Period ML13083A0052017-10-31031 October 2017 NRC Form 4 - Cumulative Occupational Dose History ML13083A0182017-10-31031 October 2017 NRC Form 64 - Travel Voucher ML13083A0592017-10-31031 October 2017 NRC Form 241 - Report of Proposed Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, or Offshore Waters ML14211A1652017-09-30030 September 2017 NRC Form 749 - Manual License Verification Report ML13083A0022017-08-31031 August 2017 NRC Form 3 - Notice to Employees ML13083A2372017-07-31031 July 2017 NRC Form 629 - Authorization for Payment by Credit Card ML13083A0502017-05-31031 May 2017 NRC Form 212 - Qualifications Investigation Professional, Technical, and Administrative Positions ML13083A0852017-03-31031 March 2017 NRC Form 327 - Special Nuclear Material (SNM) and Source Material (SM) Physical Inventory Summary Report ML19231A1992017-03-31031 March 2017 NRC Form 787 - Freedom of Information Act - User Survey ML13083A0792017-02-28028 February 2017 NRC Form 314 - Certificate of Disposition of Materials ML13083A1802017-01-31031 January 2017 NRC Form 540 - NRC Uniform Low-Level Radioactive Waste Manifest Shipping Paper ML13083A1812017-01-31031 January 2017 NRC Form 540A - Uniform Low-Level Radioactive Waste Manifest Shipping Paper (Continuation) ML13083A1822017-01-31031 January 2017 NRC Form 541 - Uniform Low-Level Radioactive Waste Manifest Container and Waste Description ML13083A0282017-01-31031 January 2017 NRC Form 136 - Security Termination Statement ML13083A1832017-01-31031 January 2017 NRC Form 541A - Uniform Low-Level Radioactive Waste Manifest Container and Waster Description (Continuation) 2022-07-11
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NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0104 EXPIRES: 03/31/2020 (04-2018) Estimated burden per response to comply with this mandatory collection request: 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br />.
Reported lessons learned are incorporated into the licensing process and fed back to LICENSEE EVENT REPORT (LER) industry. Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail (See Page 2 for required number of digits/characters for each block) to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0104), Office of Management and Budget, (See NUREG-1022, R.3 for instruction and guidance for completing this form Washington, DC 20503. If a means used to impose an information collection does not http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1022/r3/) 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.
- 1. Facility Name 2. Docket Number 3. Page 05000 1 OF
- 4. Title
- 5. Event Date 6. LER Number 7. Report Date 8. Other Facilities Involved Sequential Rev Facility Name Docket Number Month Day Year Year Month Day Year Number No. 05000 Facility Name Docket Number
- - 05000
- 9. Operating Mode 11. This Report is Submitted Pursuant to the Requirements of 10 CFR §: (Check all that apply) 20.2201(b) 20.2203(a)(3)(i) 50.73(a)(2)(ii)(A) 50.73(a)(2)(viii)(A) 20.2201(d) 20.2203(a)(3)(ii) 50.73(a)(2)(ii)(B) 50.73(a)(2)(viii)(B) 20.2203(a)(1) 20.2203(a)(4) 50.73(a)(2)(iii) 50.73(a)(2)(ix)(A) 20.2203(a)(2)(i) 50.36(c)(1)(i)(A) 50.73(a)(2)(iv)(A) 50.73(a)(2)(x)
- 10. Power Level 20.2203(a)(2)(ii) 50.36(c)(1)(ii)(A) 50.73(a)(2)(v)(A) 73.71(a)(4) 20.2203(a)(2)(iii) 50.36(c)(2) 50.73(a)(2)(v)(B) 73.71(a)(5) 20.2203(a)(2)(iv) 50.46(a)(3)(ii) 50.73(a)(2)(v)(C) 73.77(a)(1) 20.2203(a)(2)(v) 50.73(a)(2)(i)(A) 50.73(a)(2)(v)(D) 73.77(a)(2)(i) 20.2203(a)(2)(vi) 50.73(a)(2)(i)(B) 50.73(a)(2)(vii) 73.77(a)(2)(ii) 50.73(a)(2)(i)(C) Other (Specify in Abstract below or in NRC Form 366A)
- 12. Licensee Contact for this LER Licensee Contact Telephone Number (Include Area Code)
- 13. Complete One Line for each Component Failure Described in this Report Cause System Component Manufacturer Reportable to ICES Cause System Component Manufacturer Reportable to ICES
- 14. Supplemental Report Expected Month Day Year
- 15. Expected Submission Date Yes (If yes, complete 15. Expected Submission Date) No Abstract (Limit to 1400 spaces, i.e., approximately 14 single-spaced typewritten lines)
NRC FORM 366 (04-2018)
NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION (04-2018)
LICENSEE EVENT REPORT (LER) (Continued)
REQUIRED NUMBER OF DIGITS/CHARACTERS FOR EACH BLOCK BLOCK NUMBER OF TITLE NUMBER DIGITS/CHARACTERS 1 UP TO 120 / 2 LINES FACILITY NAME 8 TOTAL 2 DOCKET NUMBER 3 IN ADDITION TO 05000 3 VARIES PAGE NUMBER 4 UP TO 230 / 2 LINES TITLE 8 TOTAL 2 FOR MONTH 5 EVENT DATE 2 FOR DAY 4 FOR YEAR 9 TOTAL 4 FOR YEAR 6 LER NUMBER 3 FOR SEQUENTIAL NUMBER 2 FOR REVISIONS NUMBER 8 TOTAL 2 FOR MONTH 7 REPORT DATE 2 FOR DAY 4 FOR YEAR UP TO 37 -- FACILITY NAME 8 OTHER FACILITIES INVOLVED 8 TOTAL -- DOCKET NUMBER 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL VARIES 11 REQUIREMENTS OF 10 CFR CHECK ALL BOXES THAT APPLY UP TO 100 FOR NAME 12 LICENSEE CONTACT 10 FOR TELEPHONE CAUSE VARIES (UP TO 10) 2 FOR SYSTEM (UP TO 10) 13 4 FOR COMPONENT (UP TO 10) EACH COMPONENT FAILURE 4 FOR MANUFACTURER (UP TO 10)
ICES VARIES (UP TO 10) 1 14 SUPPLEMENTAL REPORT EXPECTED CHECK BOX THAT APPLIES 8 TOTAL 2 FOR MONTH 15 EXPECTED SUBMISSION DATE 2 FOR DAY 4 FOR YEAR 16 1400 OR 14 LINES OF TYPING ABSTRACT NRC FORM 366 (04-2018)