ML22104A051
| ML22104A051 | |
| Person / Time | |
|---|---|
| Issue date: | 04/14/2022 |
| From: | Office of Nuclear Security and Incident Response, NRC/OCIO, NRC/OGC |
| To: | |
| Cecere B | |
| Shared Package | |
| ML22005A062 | List: |
| References | |
| Download: ML22104A051 (4) | |
Text
',
- ~ l J.S.NR(_: H = -:r: 1 l*E-=-:: '1,e-:: :-E'-cCL--,-,-E-
, *, * " ' f W in l,ll.. ~ (] ~
!..,vu, rorg f1rop1,.Jrul 1/*1* I tJI 1ro,i,,w 111
1-om e Evem \\Jo:ifica ti0111 Form 36 1 A
Fo rm 3611 A
APP ROVED BY 0MB : N O. 3150 -02:3.8 EXP IRIES: 10/1112022
Estimated bu rdell per response lo c o mp ly w fth this vo run ta ry oo lec tioll requ est 30 m imlles. lihe inforn,al ioll p1ov ide d will be used fo r eva lual icm o fl'icensee e vent descriptio n, fac inly status a nd for inp11I lo the pub ic w ebs ite. Send comm e nts rega rd tng bur d en es imale lo tile FOIA, Library, and lnforma ion Co llections Branch (T-6 A10M ), U.S. Nucte a r Regu lat ory Comm ission, Wa;s hinglon. DC 2055500001, o r by e-ma il to lnfoco llects. Resou roe@nrc.g o v, a nd lhe 0MB r,eview e r at 0MB Office of I nforma fion arid Regu la to:ry Affairs, (3 1 5 0°0238 ), Alln: Desk Officer fo r the Nucl ea r Reg u laloiy Comm ission, 725 17111 S ree l NW, W ash tnglon,
DC 2 *0503 ; e"m a il: o ira _ s u b m ission@ o rnb.eop.gov. T he N.RC m a y riol conducl or sponso r, an d a. person is no t re qu ired to respond to, a co lleclion ofinfo rm a lior1 un less lhe docume nt reques ltng or requ iring lhe coUection displays a cu1 renlly v a lid 0MB con ro l n:um!Je r.
Em a il P JF re "'="' : e R _ u est
Creal!! Draft Form 36 1 A R : *: w Draft Fo rm 36 A Fin a l Fo rm 36 A
Form 3*61 A
EN Numb er
No lifi.ca tio n Dat<> A n d Time
Fa c ility o r O rga,. iza tion
- Se le<:t ' - n1 V
l i c en se N'u m b,e r
- Name o f C alle,fiitl<>
- Ca ll Ba c k INu mbe r
- Provide a telephone n umber
Event Time a n d Zo n e
- Even t Date
- Loc ation o f Eve n !
- Po rtio n o f P la nt Aftec!e <l
Eve n t Class ifica tio n s Gen era l Em erg en cy s,te A rea Em erg en cy A lert
@ o O Yea @ N o O Ye a @ N o O Ye a I
No lifica fion o f U n u su a l 1E v e11I In c iden t R ep o rt fra n sporta *fion Ev en!
@ o O Ye a @ N o O Yea I @ N o O Ye s
ln fo rm a lio n O n ly Other ( Spec ify ) Olher Sp eea ify
@ o O Yes @ No O Ye s
I I
I-
Eve n t Ty pes Fu el Cyes le ~fe-d ica l/Aca d em ic Tra n s porta 'li,011
@ o O Ye s @ No O Yes @ N o O Ye s
W aste M a n a g em e n t ln d u stria I I Comme rc fa l Fo reig n
@ o O Ye s @ No O Ye s @ N o O Ye s
Olller Other Sp eea ify
@ o O Yes l
In c ide n t Re p o rts ( 30.50, 40.60, 7 0.50 )
20. 220 1 Lo ss Tlteft (a ) Profe cli~e A c tio n Prev en ted
@ o O Y e a @ No OY es
20. 2202 ' A c tu a l/Threa ~ n ed Ov erexp os u re (b )( 1J, U' n pla 11 n e<l Co n lam in a tio n
@ o O Yes @ No OY es
20. 2202 ' A c tua 1/Thr*ea ~ n ed Re leas,e (b)( 2J, Sa fely Eq u ipm enl Fa llu re
@ No O Ye s @ No OY es
21. 21 Defect/ N'o n c o m p lia n ce (b)(3 ], Med ica l Trea tm e n t W ith Co n lam i11a lio n
@ o O Yes @ No OY es
26.7 9 1 Fitn ess F o r Du ty (b )( 4], Fire / Ex p lo sio n
@ o O Yes @ No OY es
35.3045 Med ica l EYe n t 70.!i2 ' Critica lly I S NM Lo st
@ o O Yea @ No OY es
36.83 lrra d1a to r IEve n t 70.!i2 ' A c fu a l I Attempfed Tll,eit
@ o O Ye a @ No OY es
- 39. 77 Ru pfu red W e ll L o gg in g So u rce Ap pe n d ill< A, 1 HR
@ o O Y e a @ No OY es
- 39. 77 lrrefrieva b le W ell L og g in g So u rce App e,n d ill< A 24 HR
@ o O Ye a @ No OY es
.40. 26 iailln g s / W as fe Dam Fa ltu re Co n c u rren t R epo rt
@ o O Ye a @ No OY es
Notifications Any th in g U nu s u a J o r Nlot U n derstood
@ No OYes V
State Did All Systems Fu n c tio n A~ R eq u ired
@ No OYes V
Loc a l Add itio n a l I n format io n 011 Pa ge 2'
@ No OYes V
Otli er Governme nt A gen c i1>s
Press Re lease
Even t Desc ription (!Inc lude : Sys te ms a ffected, ac tua tions a n d tllei1r initiatin g signa ls, causes, effect of even t on plan t ac tions taken or pla nne d, e tc. )
EYe nt Des c riplron
- Rad,io log ica l I Cll,e m ica l Re leases : C heck or Fill in App licab le Items
I so tope Monito r Read in g Re lea5e Activily Mo n ito r Rea din {I Re lease P hy sica l Fo rm Mon ito r Rea,d in g Chem ica l Form Mo n il.o r Read in g Re lease Re lease I I
I so tope A larm Set poin t Re tease Activ ity A la rm S..lpoin t Re lease P hy s ica J Fo rm A lam 1 Selpo in t Chem ica l Form Ala rm Setpo in l Re lease Re lease
I l I l
Stacll< Mo n ito r Read in g Re lease Uq, u id Efflu en t Mo n ito r Read in g Othe r M'o n ito r Rea din g Re lease Release ( Spec ify )
Stacll< AJa rm Setpo int Re lease Lcq, u id Efflu en t A larm Setpo in t Othe r A!anm S1>lpo in t Re lease Release ( Spec ify )
i 0 n,go rn g Re, lea s.e N u m be
- o f Pe, so n n e,I Ex pa, s.,dl Nu m b er o f Perso n n e<I Co n lam in,af ed
@ No O Yes l 7
Tenm in a tecd Re lease M= im u m & fern a l Dose M,ax im u m Ex terna l Leve l
@ N o O Yes 1 l
Olf'site Re lease MsaJ< im u m In tern a l Dose M,ax i m u m In tern a l Leve l
@ No O Yes 1 l
0 n sit!! A reas Ev a c u ated Critic.a l Orga n Exposed Critic.a l 0 rg'°'n Co n tam in ated
@ N o O Ye.s l l L L
Olf'site Pro tec tive Ac lio n Reco m meillcled +
@ N o O Ye.s t ~
N u m b er a n d Ty p1's o t Co n trn Is N'o rma l
I l
N u m b er a n d Ty p es o f Co n tro ls Up sel l
N u m b er a n d Ty p1's o t Co n tro ls Sale
I l
Sa fety Sig n ific a nc e of IEv!! n ts l
Sa fe,ty Eq u i pm!! nt Statu s
I l
Sta tu s of Co rrec tive Action,s l l
-