Ref. No.		
What is this notification related to?
	
Nuclear materials?		Associated items?		OR	Installation(s) / apparatus?		
	
Details about the incident    Refer to Explanatory Notes on the reverse of this form
	
When was the incident detected?	Date:		Time:			
	
Specific location:			
	
Description of the incident:			
	
Proposed actions to rectify situation:			
	
Assessment of impact
	
Indicate (by ticking) if the incident  affects any of the following:
(a)	The storage location for, access to, or use of nuclear material or associated items?	
(b)	The performance of facility-installed apparatus?	
(c)	The performance of any IAEA-installed containment/surveillance equipment?		
	
If any of the boxes are ticked, provide an explanation:			

Signature and permit details	
	
Name :			
	
Position:			
	Signature:	_____________________________________	Date:	____/____/________	
	
Permit Holder:		Permit No:			

Explanatory Notes

Ref. No.	 	A sequential reference number is required for each form of this type submitted by the Permit Holder (eg, 001, 002, 003, etc).  Where amendments are made to a previously submitted form, please use the same reference with a sequential revision number (eg, 003-Rev.1).	
When was the incident detected		
Incidents must be notified to ASNO within 2 hours of detection.	
Signature		This form must be signed by a representative of the Permit Holder (ie, the organisation) who will take responsibility for, and sign documents on behalf of, the organisation.

		

		

		

This form replaces the following forms 	ASO226 (Original issued 1 January 2002)