Page of

NRC FORM 361A

(07-28-2023) 

U.S. NUCLEAR REGULATORY COMMISSION

OPERATIONS CENTER 

FUEL CYCLE AND MATERIALS 

EVENT NOTIFICATION 

WORKSHEET 

APPROVED BY OMB: NO. 3150-0238 EXPIRES: 07/31/2026

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 FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, 

DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and 

Regulatory Affairs, (3150-0238), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 

20503; email: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, 

a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control 

number.

NRC FORM 361A (07-28-2023)

EN #

NRC OPERATIONS TELEPHONE NUMBERS: PRIMARY - 301-816-5100 or 800-532-3469ǂ, BACKUPS - [1st ] 301-951-0550 or 800-449-3694ǂ, 

[2nd] 301-415-0550 and [3rd] 301-415-0553. ǂLicensees who maintain their own ETS are provided these telephone numbers. FAX - 301-816-5151, EMAIL - hoo.hoc@nrc.gov

Notification Time Facility or Organization License # Name of Caller/Title Call Back #

Event Time & Zone Event Date Location of Event (Include County and State) Portion of Plant Affected (If applicable)

EVENT CLASSIFICATIONS

GENERAL EMERGENCY* 

SITE AREA EMERGENCY 

ALERT

NOTIFICATION OF UNUSUAL EVENT* 

INCIDENT REPORT 

TRANSPORATION EVENT 

INFORMATION ONLY 

EVENT TYPES

FUEL CYCLE 

MEDICAL / ACADEMIC 

TRANSPORTATION 

WASTE MANAGEMENT 

INDUSTRIAL/ COMMERCIAL 

FOREIGN EVENT

OTHER (Specify)

OTHER (Specify)

INCIDENT REPORTS (30.50, 40.60, 70.50)

20.2201 LOSS / THEFT 

20.2202 ACTUAL / THREATENED 

 OVEREXPOSURE 

20.2202 ACTUAL / THREATENED 

 RELEASE 

21.21 DEFECT / NONCOMPLIANCE 

26.791 FITNESS FOR DUTY 

35.3045 MEDICAL EVENT 

36.83 IRRADIATOR EVENT 

39.77 RUPTURED WELL 

 LOGGING SOURCE 

39.77 IRRETRIEVABLE WELL 

 LOGGING SOURCE 

40.26 TAILINGS / WASTE 

 DAM FAILURE 

 (a) PROTECTIVE ACTION 

 PREVENTED 

 (b)(1) UNPLANNED 

 CONTAMINATION 

 (b)(2) SAFETY EQUIPMENT 

 FAILURE 

 (b)(3) MEDICAL TREATMENT 

 WITH CONTAMINATION 

 (b)(4) FIRE / EXPLOSION 

 70.52 ACTUAL / ATTEMPTED 

 THEFT 

 APPENDIX A, 1-Hour

 APPENDIX A, 24-Hour

 CONCURRENT REPORT

 70.52 CRITICALITY / SNM LOST 

 *ONLY UNDER OLD 1981 ORDER

NOTIFICATIONS

NRC REGION

YES NO WILL 

BE

STATE(s)

LOCAL

OTHER GOVERNMENT 

AGENCIES

PRESS RELEASE

Anything Unusual or not understood? Yes (Explain below) No

Did all systems function as required? Yes No (Explain below)

Additional Information on page 2? Yes No

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) 
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NRC FORM 361A

(07-28-2023) FUEL CYCLE AND MATERIALS 

EVENT NOTIFICATION WORKSHEET (Continued) 

U.S. NUCLEAR REGULATORY COMMISSION

OPERATIONS CENTER 

NRC FORM 361A (07-28-2023)

EN #

RADIOLOGICAL / CHEMICAL RELEASES: CHECK OR FILL IN APPLICABLE ITEMS

Isotope Activity Physical Form Chemical Form Stack Liquid Effluent Other (Specify)

Monitor Reading 

 Alarm Setpoint 

Event Description (Continued) (Include: Systems affected, actuations and their initiating signals, causes, effect of event on plant, actions taken or planned, etc.)

ONGOING RELEASE 

TERMINATED RELEASE 

OFFSITE RELEASE 

ONSITE AREAS EVACUATED 

OFFSITE PROTECTIVE 

ACTION RECOMMENDED 

PERSONNEL EXPOSURE / CONTAMINATION DATA

Number of Personnel Exposed

Maximum External Dose

Maximum Internal Dose

Critical Organ (if known) Critical Organ (if known)

Maximum Internal Level

Maximum External Level

Number of Personnel Contaminated

Number and Types of controls necessary under normal operating conditions

Number and Types of controls which functioned properly under upset conditions

Number and Types of controls necessary to restore a safe situation

Safety Significance of Events

Safety Equipment Status

Status of Corrective Actions