| Personal information of the Person/Staff completing the incident report form | Name |
| Title/Position | |
| Job Description | |
| Date and Signature | |
| Names of Witnesses (if any) |
|
| INCIDENT DESCRIPTION | |
| Date and time the incident occurred | Date: Time: |
| Location of the incident |
|
| Component/System affected |
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| Safety classification of the component/system (SSCs) | Safety Class 1 Safety Class 2 Safety Class 3 Safety Class 4 |
| Description of the incident |
|
| Immediate actions taken to contain the incident or secure the incident area |
|
| Can the incidence be resolved within three (3) working days? | Yes, the incident can be resolved No, the incident cannot be resolved |
| Actions taken to resolve the incident (or Actions to be taken to resolve the incident if the resolution is not possible within 3 working days). |
|
| Number of day(s) taken to resolve the incident |
|
| Can the Reactor be operated without resolving the incident? | Yes, the Reactor can be operated No, the Reactor cannot be operated |
| INCIDENT REPORTING (REPORT THE INCIDENT WITHIN 7 WORKING DAYS) | |
| Date and Time the incident reported to the Manager |
|
| Date and Time the Manager reported the incident to the: | |
| Director |
|
| Reactor Safety Committee |
|
| GAEC Security |
|
| Director General |
|
| NRA |
|