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

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

Enter the code as it is shown:

  

If you have questions or need more information, please contact Ashley Ruocco at ashley.ruocco@hq.doe.gov or at
(301) 903-7010.