ML19023A234

NRC 176 (Draft 6) (01-22-2019)

ML19023A234
Person / Time
Issue date:	01/22/2019
From:	Bertinia Smith-Butler NRC/ADM/DFS/SMOB
To:
Smith-Butler B
Shared Package
ML19016A375	List: ML19016A377 ML19023A234
References
Download: ML19023A234 (4)

Text

NRC FORM 176 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0049 EXPIRES: (MM/DD/YYYY)

(MM-YYYY) Estimated burden per response to comply with this mandatory information collection request: XX NRC MD 12.3 minutes. This submittal is used by NRC to initiate termination of access authorization. Send comments regarding burden estimate to the Information Services Branch (O-1 F21), U.S. Nuclear A. SECURITY ACKNOWLEDGMENT Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.

gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0049), 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.

INSTRUCTIONS: Applicants for U.S. Nuclear Regulatory Commission (NRC) Access Authorization (Security Clearance),

Complete Section A. and C.

Applicants for Special Nuclear Material Access Authorization (employees of licensed organizations or other individuals affected by 10 CFR Part 11). Complete Section B. and C.

I, , in anticipation of my access authorization by the United States Nuclear Regulatory Commission (NRC), make the following statement with the understanding and intent that my statement will be used by the NRC in carrying out its obligation to protect the security of Restricted Data and Controlled Unclassified Information.

1. I understand that it is the policy of the NRC to control the dissemination of Restricted Data, and Controlled Unclassified Information (e.g., privacy information, Safeguards Information, and proprietary information) in such a manner as to assure the common defense and security.

2. I understand that, in carrying out this policy, the NRC has issued and will issue and revise, as circumstances require, certain instructions and regulations pertaining to the control and dissemination of Restricted Data, and Controlled Unclassified information.

3. I shall not unlawfully reveal to any person any Restricted Data, or Controlled Unclassified Information, of which I may gain knowledge as a result of my employment assignment, or duties, except as authorized by law, regulations of the NRC, or in writing by officials of the NRC empowered to grant permission for such disclosure.

4. I am aware that the Atomic Energy Act of 1954, as amended, U.S. Code, Title 18, "Crimes and Criminal Procedures," and 32 Code of Federal Regulations, Part 2002, "Controlled Unclassified Information prescribe penalties for unauthorized disclosure of Restricted Data, Formerly Restricted Data, Controlled Unclassified Information, and other information relating to the national defense, and for loss, destruction or compromise of such information through gross negligence.

5. I am aware that, unless and until I am released in writing by an authorized representative of the U.S. Government, all conditions and obligations imposed upon me by virtue of my having executed SF 189, Classified Information Nondisclosure Agreement, or SF 312 of the same title, remain in full force and effect.

6. I am aware that I may be liable for damages if I reveal to any unauthorized person Controlled Unclassified information (e.g., privacy information, proprietary information) of which I have gained Knowledge as a result of my employment, affiliation with NRC.

7. I understand that revealing or disclosing Restricted Data or Controlled Unclassified Information, to any unauthorized personnel constitute sufficient cause for termination or my association with the NRC.

8. I understand that the NRC desires to be informed when persons granted NRC security clearance propose to travel to designated countries NRC wishes to be advised of such travel in order to inform the individual of the possible risks to personal safety in view of the classified information known to the individual. Informing the NRC of travel to designated countries does not apply to individuals who obtain an NRC security clearance and receive access to NRC classified information solely as employees of other Government agencies or their contractors.

9. I am aware that I may be subject to criminal penalties if I make any statement of material facts on my personnel security forms or related information in application for my NRC security clearance knowing that such statement is false or if I willfully conceal any material fact (Title 18, U.S. Code, Section 1001).

10. I understand that I am to comply with all reporting requirements. I agree to notify the NRC, Division of Facilities and Security, within 5 days of reportable information as set forth in Security Executive Agent Directive (SEAD 3) or other applicable guidance, including but not limited to, arrests, charges (INCLUDING CHARGES THAT ARE DISMISSED) or detentions by Federal State or other law enforcement authorities, for any violation of any Federal, military, State, county or municipal law, regulation or ordinance other than minor traffic violations for which a fine of $150 or less was imposed, occurring during any period in which I may hold NRC security clearance or which occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or Standard Form 86C, "The Standard Form 86 Certification."

Date Social Security Number (Last 4 digits) Signature City and State where Signed Name of Employer NRC FORM 176 (MM-YYYY) Page 1

NRC FORM 176 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

NRC MD 12.3 B. SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION ACKNOWLEDGMENT I, , in anticipation of my special nuclear material access authorization ("U" or "R") by the United States Nuclear Regulatory Commission (NRC), make the following statement with the understanding and intent that my statement will be used by the NRC in carrying out its obligation to assure the control and safeguarding of special nuclear material in accordance with the terms of the Atomic Energy Act of 1954, as amended. I understand that:

1. It is the policy of the NRC to regulate access to, and provide for control over, special nuclear material in such a manner as to provide high assurance that activities involving such materials are not inimical to the common defense and security and do not constitute an unreasonable risk to the public health and safety.

2. I understand, that in carrying out this policy, the NRC has issued, and will issue and revise as circumstances require, certain instructions and regulations pertaining to access to and control of special nuclear material.

3. Any theft or other unlawful diversion of special nuclear material, or any attempt or conspiracy to steal, or unlawfully divert such material, is a criminal violation of the Atomic Energy Act of 1954, as amended, and subject to criminal penalties.

4. I understand that I am to notify the NRC, Division of Facilities and Security, within 5 days of all arrests, charges (INCLUDING CHARGES THAT ARE DISMISSED) or detentions by Federal, State or other law enforcement authorities, for any violation of any Federal, military, State, county or municipal law, regulation or ordinance other than minor traffic violations for which a fine of $150 or less was imposed, occurring during any period in which I may hold an NRC special nuclear material access authorization or which occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or Standard Form 86C, "The Standard Form 86 Certification."

Date Social Security Number (Last 4 digits) Signature City and State Where Signed Name of Employer NRC FORM 176 (MM-YYYY) Page 2

NRC FORM 176 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10CFR11 C. SECURITY DEBRIEFING ACKNOWLEDGEMENT I reaffirm that the provisions of the espionage laws, other federal criminal laws and executive orders applicable to the safeguarding of classified information, Restricted Data, National Security Information, or Controlled Unclassified Information, have been made available to me; I have returned or destroyed, in accordance with NRC security regulations, all classified and/or sensitive information which I may have had in my custody; I will not communicate or transmit classified information to any unauthorized person or organization; I will promptly report to the Federal Bureau of Investigation any attempt by an unauthorized person to solicit classified information, and I Have Received A Security Debriefing. I Have Not Received A Security Debriefing.

Date Social Security Number (Last 4 digits) Signature of Employee Typed or Printed Name of Witness Signature of Witness

PRIVACY ACT STATEMENT SECURITY ACKNOWLEDGMENT/SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION ACKNOWLEDGMENT NRC FORM 176 Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579),

the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 176. This information is maintained in a system of records designated as NRC-39 and described at 81 Federal Register 81348 (November 17, 2016), or the most recent Federal Register publication of the NRC's Republication of Systems of Record Notices that is located in the NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 42 U.S.C. 2011 et seq,; 42 U.S.C. 2165, 2001(I); 2201A, AND 2284; 42 U.S.C. 5801 et seq.;

Executive Order (E.O.) 9397; as amended by E.O. 13478; E.O. 10450, as amended; E.O. 10865, as amended; E.O. 13467; E E.O. 13526, E.O. 13587; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised, 5 CFR 731, 732, and authorities cited therein.

2. PRINCIPAL PURPOSE(S): An individual's signature on this form initiates action to terminate his/her access authorization and indicates an individual's acknowledgment/acceptance of continuing responsibilities following the termination of their access authorization and/or employment for the protection of classified and sensitive unclassified information that individual had access to in the course of performing official duties.

3. ROUTINE USE(S): Information may be used on a need-to-know basis by NRC officials, Hearing Examiners, Personnel Security Review Panel members, OPM, CIA and other Federal agencies to determine/certify clearance or access authorization; to determine eligibility for access to NRC buildings or access to Federal automated information systems or data; to maintain the NRC personnel security program; and to provide licensees criminal history information needed for their unescorted access or access to safeguards information determinations. Information may be disclosed in accordance with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding. In addition, this information may be transferred 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. Information may also be disclosed, 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, or to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information. However, non-receipt of this signed form may result in a failure to terminate an individual's access authorization.

5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.