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) | |
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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 3611 A APPROVED BY 0MB: NO. 3150-02:3.8 EXPIRIES: 10/1112022 Estimated burdell per response lo comply wfth this voruntary oo lectioll request 30 mimlles. lihe inforn,alioll p1ovided will be used for evalualicm of l'icensee event description, facinly status and for inp11I lo the pub ic website. Send comments regardtng burden es imale lo 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 I nformafion arid Regulato:ry Affairs, (3150°0238), Alln: Desk Officer for the Nuclear Regulaloiy Commission, 725 17111 S reel NW, Washtnglon, DC 2*0503; e"mail: oira_submission@ornb.eop.gov. The N.RC may riol conducl or sponsor, and a. person is not required to respond to, a colleclion ofinformalior1 unless lhe document requesltng or requiri ng lhe coUection displays a cu1renlly valid 0MB con rol n:um!Jer.
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e R _ uest Creal!! Draft Form 36 1 A R: *:w Draft Form 36 A Final Form 36 A Form 3*61 A EN Number Nolifi.cation Dat<> And Time Facility or Orga,.ization
- Sele<:t ' - n1 V
l icense N'umb,er
- Name of C alle,fii tl<>
- Call Back INu mber
- Provide a telephone number Event Time and Zo ne
- Event Date
- Location of Even!
- Portion of Plant Aftec!e<l
Event Classifications General Emergency o O Yea Nolificafion of Un usual 1Eve11I o O Yea lnformalion Only o O Yes Event Types Fuel Cyesle o O Yes Waste Man agement o O Yes Olll er o O Yes Incident Reports (30.50, 40.60, 70.50) 20.2201 Loss Tlteft o O Yea 20.2202' Actual/Threa~ ned Over exposure o O Yes 20.2202' Actua 1/Thr*ea~ ned Releas,e
@ No O Yes 21.21 Defect / N'oncompliance o O Yes 26.791 Fitness For Duty o O Yes 35.3045 Medical EYent o O Yea 36.83 lrrad1ator IEvent o O Yea 39.77 Rupfu red Well Logging Source o O Yea 39.77 lrrefrieva ble Well Logging Source o O Yea
.40.26 iaillngs / Wasfe Dam Fal ture o O Yea I
I I-s,te Area Emergency
@ No O Yea In ci dent Report
@ No O Yea Other (Specify)
@ No O Yes
~fe-dical/Academic
@ No O Yes ln du stria I I Commercfal
@ No O Yes Other Speeaify I
I l
Alert
@ No O Yea f ransporta*fion Even!
@ No O Yes Olher Speeaify Trans porta'li,011
@ No O Yes Foreign
@ No O Yes (a) Profecli~e Action Prevented
@ No OYes (b)(1J, U'npla11ne<l Conlamination
@ No OYes (b)(2J, Safely Equipm enl Fal lure
@ No OYes (b)(3], Medical Treatment Wit h Conlam i11alion
@ No OYes (b)(4], Fir e / Explosion
@ No OYes 70.!i2' Critically I S NM Lost
@ No OYes 70.!i2' Acfual I Attempfed Tll,eit
@ No OYes Appendill< A, 1 HR
@ No OYes Appe,ndill< A 24 HR
@ No OYes Concurrent Report
@ No OYes
Notifications State Local Otli er Government A gen ci1>s Press Release V
V V
Anything Unu s uaJ or Nlot Understood
@ No OYes Did All Systems Function A~ Required
@ No OYes Additional Information 011 Page 2'
@ No OYes Event Description (!Include: Systems affected, actuations and tllei1r initiating signals, causes, effect of event on plant actions taken or planned, etc.)
EYent Descriplron
- Rad,iological I Cll,emical Releases: Check or Fill in Applicable Items Isotope Monitor Reading Relea5e Isotope Alarm Set point Retease I
l Stacll< Monitor Reading Release Stacll< AJarm Setpoint Release i
Activily Monitor Readin{I Release Activity Alarm S..lpoint Release I
Uq,uid Effluent Monitor Reading Release Lcq,uid Effluent Alarm Setpoint Release Physica l Form Monitor Rea,ding Release Phys icaJ Form Alam1 Selpoint Release Other M'onitor Reading Release (Specify)
Other A!anm S1>lpoint Release (Specify)
I l
Chemical Form Monil.o r Read ing Release Chemical Form Alarm Setpoinl Release I
0 n,gorng Re,lea s.e N um be* of Pe, son ne,I Expa,s.,dl Number of Person 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'site Release MsaJ<imum Internal Dose M,axi mum Internal Level
@ No O Yes 1
l 0 nsit!! Areas Evacuated Critic.al Organ Exposed Crit ic.al 0 rg'°'n Co ntaminated
@ No O Ye.s l
l t
L L
Olf'site Protective Aclio n Recommeillcled
+
@ No O Ye.s
~
Number and Typ1's ot Co ntrn Is N'ormal I
l Number and Types of Co ntrols Upsel l
Number and Typ1's ot Co ntrols Sale I
l Safety Significance of IEv!!nts l
Safe,ty Equi pm!!nt Statu s I
l Status of Corrective Action,s l
l
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