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|  DOE-STD-1045-93
(SAMPLE) PERSONAL STATEMENT
Subject or Title of Event
Event Date/Time
Occurrence Report Number
In your own words, write down what happened in the event. Include any relevant information
from before the event began until after it was over. Include the following:
1.
Facility or system conditions as you know
4.
Your actions in response to the
them prior to the event.
indications.
2.
What you were doing immediately prior to
5.
Any equipment malfunctions.
the event.
3.
Any indications that a problem existed.
6.
Any inadequacies in the procedures,
practices, or training.
Completed By
Signature
Date/Time
If additional sheets are used, each sheet should contain: signature, date, time, event title, and
occurrence report number.
A-3
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