ORPS Quality Feedback Form

** Occurrence Report #:
** OR Subject / Title:
** OR Report Date:
** Date OR Reviewed:
** Your name:
** Organization:
** Telephone number:
** E-mail:

Check the field(s) where you have concern(s):

Facility / Personnel Information

Name of Facility	Facility Function
Name of Lab, Site, or Organization	Facility Manager / Designee
Originator Transmitter	Authorized Classifier

Specific Report Items

1. OR Number	17. Operating Conditions
2. Report Type and Date	18. Activity Category
3. Occurrence Category	19. Immediate Actions Taken
4. Number of Occurrences	20. Direct Cause
5. Division or Project	21. Contributing Cause(s)
6. DOE Secretarial Office	22. Root Cause
7. System, Bldg, or Equip.	23. Description of Cause
8. UCNI	24. Evaluation by Facility Manager
9. Plant Area	25. Further Evaluation Required
10. Date and Time Discovered	26. Corrective Actions
11. Date and Time Categorized	27. Impact on ES&H
12. DOE Notification	28. Programmatic Impact
13. Other Notifications	29. Impact on Codes/Standards
14. Subject or Title of Occurrence	30. Lessons Learned
15. Nature of Occurrence	31. Similar OR Numbers
16. Description of Occurrence	32. Signatures

For each field selected above, provide a specific statement of the concern(s):

  

If you have questions or need more information, please contact Eugenia Boyle at eugenia.boyle@hq.doe.gov or at 301.903.3393.