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Category:NRC Forms (Blank)
MONTHYEARML22192A1972022-07-11011 July 2022
NRC Form 446 - Request for Approval of Official Foreign Travel by Non-Government Personnel (*Must Be Completed 30 Days Prior to Travel)
ML21148A2422021-05-28028 May 2021
NRC Form 149 - Ocfo Invitational Traveler Request Form
ML20339A6732021-01-12012 January 2021
NRC Form 529 - Dispute of Fees-for-Service Charges in Accordance with Title 10 of the Code of Federal Regulations (10 CFR) 170.51
ML12164A7272020-01-31031 January 2020
NRC Form 313A (Amp), Authorized Medical Physicist or Ophthalmic Physicist, Training, Experience and Preceptor Attestation (10 CFR 35.51, 35.57(a)(3), and 35.433). (01-2020)
ML12164A7282020-01-31031 January 2020
NRC Form 313A (Anp), Authorized Nuclear Pharmacist Training, Experience, and Preceptor Attestation (10 CFR 35.55). (01-2020)
ML12164A7332020-01-31031 January 2020
NRC Form 313A (Aud), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.100, 35.200, and 35.500) (10 CFR 35.57, 35.190, 35.290, and 35.590). (01-2020)
ML12164A7362020-01-31031 January 2020
NRC Form 313A (Aus), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.400 and 35.600) (10 CFR 35.57, 35.490, 35.491, and 35.690). (01-2020)
ML12164A7412020-01-31031 January 2020
NRC Form 313A (Aut), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.300)(10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396). (01-2020)
ML12164A7422020-01-31031 January 2020
NRC Form 313A (Rso), Radiation Safety Officer or Associate Radiation Safety Officer Training, Experience, and Preceptor Attestation (10 CFR 35.57, 35.50). (01-2020)
ML13083A1032019-10-31031 October 2019
NRC Form 361N - Non-Power Reactor (NPR) Event Notification Worksheet
ML13083A0722019-09-30030 September 2019
NRC Form 313 - Application for Materials License
ML13083A0192019-07-31031 July 2019
NRC Form 7 - Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(S)
ML13083A1232019-07-31031 July 2019
NRC Form 396 - Certification of Medical Examination by Facility Licensee
ML13083A1272019-07-31031 July 2019
NRC Form 398 - Personal Qualification Statement -- Licensee
ML13083A1742019-07-31031 July 2019
NRC Form 526 - Certification of Small Entity Status for the Purposes of Annual Fees Imposed Under 10 CFR Part 171 (Effective July 16, 2019)
ML13083A1762019-05-31031 May 2019
NRC Form 531 - Request for Taxpayer Identification Number
ML13083A2502019-04-30030 April 2019
NRC Form 664 - General Licensee Registration
ML19231A2062019-01-31031 January 2019
NRC Form 527 - Request for Information Related to Contractor Charges -- in Accordance with 10 CFR 170.51
ML16025A0332018-12-31031 December 2018
NRC Form 405F - List All Owners, Officers, Directors, and Executive Personnel (Oodep'S)
ML13083A1372018-10-31031 October 2018
NRC Form 426 - Authorization to Publish a Manuscript in the NUREG Series
ML13083A0942018-06-30030 June 2018
NRC Form 354 - Data Report on Spouse
ML13083A1422018-05-31031 May 2018
NRC Form 445 - Request for Approval of Official Foreign Travel
ML13083A1522018-04-30030 April 2018
NRC Form 483 - Registration Certificate -- in Vitro Testing with Byproduct Material Under General License
ML13083A1072018-04-30030 April 2018
NRC Form 366A - Licensee Event Report (LER) Continuation Sheet
ML13083A1062018-04-30030 April 2018
NRC Form 366 - Licensee Event Report (LER)
ML13083A2952018-04-30030 April 2018
NRC Form 740M - Concise Note
ML13083A2972018-04-30030 April 2018
NRC Form 742 - Material Balance Report
ML13083A2982018-04-30030 April 2018
NRC Form 742C - Physical Inventory Listing
ML13083A2962018-04-30030 April 2018
NRC Form 741 - Nuclear Material Transaction Report
ML13083A2442018-02-28028 February 2018
NRC Form 653 - Transfers of Industrial Devices Report (to General Licensees)
ML13083A1082018-02-28028 February 2018
NRC Form 366B - Licensee Event Report (LER)
ML13114A5072017-12-31031 December 2017
NRC Form 782 - Complaint Form
ML13083A3292017-12-31031 December 2017
NRC Form 781 - Sbcr Compliance Review Part a
ML13083A1792017-11-30030 November 2017
NRC Form 536 - Operator Licensing Examination Data
ML13083A0172017-10-31031 October 2017
NRC Form 5 - Occupational Dose Record for Monitoring Period
ML13083A0052017-10-31031 October 2017
NRC Form 4 - Cumulative Occupational Dose History
ML13083A0182017-10-31031 October 2017
NRC Form 64 - Travel Voucher
ML13083A0592017-10-31031 October 2017
NRC Form 241 - Report of Proposed Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, or Offshore Waters
ML14211A1652017-09-30030 September 2017
NRC Form 749 - Manual License Verification Report
ML13083A0022017-08-31031 August 2017
NRC Form 3 - Notice to Employees
ML13083A2372017-07-31031 July 2017
NRC Form 629 - Authorization for Payment by Credit Card
ML13083A0502017-05-31031 May 2017
NRC Form 212 - Qualifications Investigation Professional, Technical, and Administrative Positions
ML13083A0852017-03-31031 March 2017
NRC Form 327 - Special Nuclear Material (SNM) and Source Material (SM) Physical Inventory Summary Report
ML19231A1992017-03-31031 March 2017
NRC Form 787 - Freedom of Information Act - User Survey
ML13083A0792017-02-28028 February 2017
NRC Form 314 - Certificate of Disposition of Materials
ML13083A1802017-01-31031 January 2017
NRC Form 540 - NRC Uniform Low-Level Radioactive Waste Manifest Shipping Paper
ML13083A1812017-01-31031 January 2017
NRC Form 540A - Uniform Low-Level Radioactive Waste Manifest Shipping Paper (Continuation)
ML13083A1822017-01-31031 January 2017
NRC Form 541 - Uniform Low-Level Radioactive Waste Manifest Container and Waste Description
ML13083A0282017-01-31031 January 2017
NRC Form 136 - Security Termination Statement
ML13083A1832017-01-31031 January 2017
NRC Form 541A - Uniform Low-Level Radioactive Waste Manifest Container and Waster Description (Continuation)
2022-07-11
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NRC FORM 445 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0193 EXPIRES: 05/31/2021 (05-2018) Estimated burden per response to comply with this voluntary collection request: 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. NRC uses this form to NRC MD 14.1 authorize foreign travel for non-Federal personnel in the course of conducting business for the NRC. Send REQUEST FOR APPROVAL OF comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk OFFICIAL FOREIGN TRAVEL Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0193), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection .
A. TRAVELER INFORMATION (To be completed by traveler)
Name of Traveler Position Title Country of Travel Departure Date Return Date Is your official passport valid? Does your trip require a visa?
Yes No Yes No I will adhere to all ethical codes of conduct while on travel. I understand that I must contact the NRC Health Center (301) 415-8400 to consult on possible medical issues and precautions, including recommended inoculations or other medications and educational materials.
Signature of Traveler Signature Date Purpose of Travel (Please provide a brief description of the purpose for your travel. Please spell out all acronyms.)
List of Persons with whom Travel has been coordinated (Name and Agency)
NAME AGENCY/OFFICE (i.e., Supervisor, OIP Desk Officer, other travelers)
B. REVIEW AND APPROVAL Signature of Office Director/Regional Administrator Signature Date Signature of Deputy Director, OIP (if required) Signature Date Signature of Chairman (if required) Signature Date NRC FORM 445 (05-2018) Page 1 of 3
NRC FORM 445 U.S. NUCLEAR REGULATORY COMMISSION (05-2018)
NRC MD 14.1 REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)
C. TRAVEL ITINERARY Location Contact on Site "X" If Date Activity (City, Country) (Name, telephone number, and e-mail address) Classified D. FUNDING Source of Funding Job Code NRC FORM 445 (05-2018) Page 2 of 3
NRC FORM 445 U.S. NUCLEAR REGULATORY COMMISSION (05-2018)
NRC MD 14.1 REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)
PRIVACY ACT STATEMENT NRC FORM 445 REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 445. This information is maintained in a system of records designated as NRC-20 and described at 81 Federal Register 81334-81335 (November 17, 2016), or the most recent Federal Register publication of the NRC's Republication of Systems of Records Notices located in the NRC's Agencywide Documents Access and Management System (ADAMS).
- 1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter 61; 41 CFR 102-118; Executive Order (E.O.) 9397, as amended by E.O. 13478.
- 2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.
- 3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may disclose information from this system of records to the U.S. Treasury for payment; the Department of State or an embassy for passports or visas; the General Services Administration and the Office of Management and Budget for required periodic reporting; the charge card issuing bank; the Department of Interior, National Business Center, for collecting severe travel card delinquencies by employee salary offset; and to a consumer reporting agency to obtain credit reports. The information may also be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; and to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.
- 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided approval for foreign travel may be denied.
- 5. SYSTEM MANAGER AND ADDRESS: Chief, International Operations Branch, Office of International Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.
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