ML18081A491

Draft NRC Form 361N, Non-Power Reactor (NPR) Event Notification Worksheet

ML18081A491
Person / Time
Issue date:	09/27/2018
From:	NRC/OCIO
To:
References
Download: ML18081A491 (1)

Text

NRC FORM 361N (MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION OPERATIONS CENTER 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-2 F43), 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.

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-XXXX NON-POWER REACTOR (NPR)

EVENT NOTIFICATION WORKSHEET NRC FORM 361N (MM-YYYY)

Page of Continued on next page EN #NRC OPERATIONS TELEPHONE NUMBERS: PRIMARY - 301-816-5100 or 800-532-3469, BACKUPS - [1st ] 301-951-0550 or 800-449-3694, [2nd] 301-415-0550 and [3rd] 301-415-0553. Licensees who maintain their own ETS are provided these telephone numbers.

FAX - 301-816-5151, EMAIL - hoo.hoc@nrc.gov Notification Time Name of Caller/Title Unit Facility or Organization Call Back #

Event Date Event Time & Zone Power/Mode (At Time of Event)

Power/Mode (At Time of Notification)

EVENT CLASSIFICATION GENERAL EMERGENCY SITE AREA EMERGENCY ALERT UNUSUAL EVENT SAFEGUARDS EVENT (73 App G)

MATERIAL/EXPOSURE GEN/AAEC SIT/AAEC ALE/AAEC UNU/AAEC B???? TS Deviation TS Required S/D RPS Actuation (scram)

Offsite Notification Degraded Condition

Unanalyzed Condition

Specified System Actuation Safe S/D Capability

Control of Rad Release Accident Mitigation

Offsite Medical

Loss Comm/Asmt/Resp Invalid Specified System Act ADEV ASHU ARPS APRE ADEG AUNA AESF AINA AINC AIND AMED ACOM AINV OTHER UNSPECIFIED REQUIREMENT (IDENTIFY)

NONR NONR 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)

INFORMATION ONLY NNF OTHER UNSPECIFIED REQMT (see last column)

NOTIFICATIONS HQ NPR STAFF YES NO WILL BE STATE(s)LOCAL OTHER GOV AGENCIES MEDIA/PRESS RELEASE Anything Unusual or not understood?

Did all systems function as required?

Mode of operation until corrected (if applicable)

Yes (Explain above)

No Yes No (Explain above)

Additional Information continued on next page?

Yes No Reactor Type Max Power Max Pulse Pulse Inserted During Event REPORTABLE CONDITION (varies by facility TS)

Suspicious Activity Security Event Estimate for restart date:

NRC FORM 361N (MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION OPERATIONS CENTER NON-POWER REACTOR (NPR)

EVENT NOTIFICATION WORKSHEET (Continued)

NRC FORM 361N (MM-YYYY)

Page of EN # 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

• State release path in description Release Rate (Ci/sec)

% T.S. Limit HOO Guide Total Activity (Ci)

% T.S. Limit HOO Guide Noble Gas 0.1 Ci/sec 1000 Ci Iodine 10 Ci/sec 0.01 Ci Particulate 1 Ci/sec 1 mCi Liquid (excluding tritium and dissolved noble gas) 10 Ci/min 0.1 Ci Liquid (tritium)0.2 Ci/min 5 Ci Total Activity List of Safety Related Equipment not Operational RADIOLOGICAL RELEASES: CHECK OR FILL IN APPLICABLE ITEMS (specific details/explanations should be covered in event description)

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)