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
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!..,vu, rorg f1rop1, .Jrul 1/*1* I tJI 1ro,i,,w 111 1- ome Evem \Jo:ificati0111 Form 36 1 A Form 3611A APPROVED BY 0MB: NO. 3150-02:3.8 EXPIRIES: 10/1112022 Estimated bu rdell per response lo comply wfth this voruntary oo lectioll request 30 mimlles. lihe inforn,alioll p1ovided will be used f or evaluali cm of l'icensee event description, facinly status and for inp11I lo the pub ic website. Send comments regardtng burden es imale l o tile FOIA, Library, and lnforma ion Collections Branch (T-6 A10M), U.S . Nuctear Regulatory Commission, Wa;shinglon. DC 2055500001 , or by e-mail to lnfocollects.Resouroe@nrc.gov, and lhe 0MB r,eviewer at 0MB Office of Informafion arid Regulato:ry Affairs, (31 50°0238), Alln: Desk Officer for the Nuclear Regulaloiy Commission , 725 17111 S reel NW, Washtnglon, DC 2*0 503; e"mail: oira_s ubmission@ornb.eop.gov. The N.RC may riol conducl or sponsor, and a. person is not required t o respond to, a colleclion ofinform alior1 unless lhe document requesltng or requiri ng lhe coUection displays a cu1renlly valid 0MB con rol n:um!Jer.
Email P JF re "'="' : e R _ uest Creal!! Draft Form 36 1 A R: *:w Dr aft For m 36 A Final Form 36 A Form 3*61 A EN Number Nolifi.cation Dat<> And Time Fa cil ity or Orga,.i za tion
- Sele<:t ' - n1 V l icense N'u mb,er
- Name of C alle,fii tl<>
- Call Bac k INu mber
- Provide a telephone number Event Time and Zo ne
- Event Date
- Location of Even!
- Porti on of Plant Aftec!e<l
Event Classifications Gen eral Emergen cy s,te Area Emergency A lert
@ o O Yea @ No O Yea @ No O Yea I
Nolificafion of Un usu al 1Ev e11I In ci dent Rep ort f ran sporta*fion Even!
@ o O Yea @ No O Yea I @ No O Yes ln fo rmalion Only Other (Specify) Olher Sp eeaify
@ o O Yes @ No O Yes I
I I-Event Types Fu el Cyesle ~fe-di cal/Academic Tran sporta'li,011
@ o O Yes @ No O Yes @ No O Yes Waste Man agement ln du striaI I Commercfa l Foreign
@ o O Yes @ No O Yes @ No O Yes l
Olll er Other Sp eeaify
@ o O Yes Incident Reports (30 .50, 40.60, 70.50 )
20.2201 Loss Tlteft (a) Profecli~e Act ion Prevented
@ o O Yea @ No OYes 20.2202' Act ual/Threa~ ned Over exposure (b)(1J, U'npla11ne<l Conlam in ati on
@ o O Yes @ No OYes 20.2202' Actua 1/Thr*ea~ ned Releas,e (b)(2J, Safely Equi pm enl Fal l ure
@ No O Yes @ No OYes 21.21 Defect / N'on compliance (b)(3], Medical Treatment Wit h Con lam i11alion
@ o O Yes @ No OYes 26.791 Fitn ess For Duty (b)(4], Fir e / Exp losion
@ o O Yes @ No OYes 35.3045 Medical EYent 70.!i2' Critical ly I SNM Lost
@ o O Yea @ No OYes 36.83 lrra d1ator IEvent 70.!i2' Ac fu al I Attempfed Tll,eit
@ o O Yea @ No OYes 39.77 Rupfu red Well L ogging Source Appendill< A, 1 HR
@ o O Yea @ No OYes 39.77 lrrefri eva bl e Well L ogging Source App e,ndill< A 24 HR
@ o O Yea @ No OYes
.40.26 iaillngs / Wasfe Dam Fal ture Conc urrent Report
@ o O Yea @ No OYes
Notifications Anyth in g Unu suaJ or Nlot Un derstood
@ No OYes V
State Did Al l Systems Fun ction A~ Required
@ No OYes V
Local Additio n al Informat ion 011 Page 2'
@ No OYes V
Otli er Government Agen ci1>s Press Release Even t Description (!Include: Systems affected , actuations and tllei1r initiatin g signals, causes , effect of event on plant actions taken or planned, etc. )
EYent Descriplron
- Rad,iolog ica l I Cll,emica l Releases: Check or Fill in Applicable Items Isotope Monitor Reading Relea5e Activi ly Monitor Readi n{I Release Phy sica l Form Monitor Rea,d i ng Chemical Form Mon il.o r Read in g Release Release I I Isotope Alarm Set point Retease Activity Alarm S..lpoi nt Rel ease Phy sicaJ Form Alam1 Selpoint Chemical Form Al arm Setpo inl Release Release l
I I Stacll< Monitor Readin g Rel ease Uq,uid Efflu ent Monitor Reading Other M'onitor Rea ding Release l
Release (Specify)
Stacll< AJar m Setpoint Release Lcq,ui d Efflu ent Alarm Setpoint Ot her A!anm S1>l poi nt Rel ease Release (Specify) i
0 n,gorng Re,lea s.e N um be* o f Pe, son ne,I Expa,s.,dl Num ber o f Per son ne<I Con lamin,afed
@ No O Yes l 7 Tenmin atecd Release M= imum & fernal Dose M,axim u m External Level
@ No O Yes 1 l Olf'si te Release MsaJ<imum Intern al Dose M,axi mum Internal Level
@ No O Yes 1 l 0 n sit!! Areas Evacu ated Critic.al Organ Exposed Crit ic.al 0 r g'°'n Co ntamin ated
@ No O Ye.s L l L l Olf'si te Pr otective Aclio n Recommeillcled
+
@ No O Ye.s t ~
Num ber and Typ1's o t Co ntrn Is N'or mal I
l Num ber and Types o f Co ntrols Upsel l
Num ber and Typ1's o t Co ntro ls Sale I
l Safety Sign ifi cance of IEv!!nts l
Safe,ty Equ i pm!!nt Statu s I
l Status of Corrective Action,s l
l
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