ML19205A095
| ML19205A095 | |
| Person / Time | |
|---|---|
| Issue date: | 07/29/2019 |
| From: | Office of Administration |
| To: | |
| Robbins E | |
| Shared Package | |
| ML19205A094 | List: |
| References | |
| Download: ML19205A095 (3) | |
Text
NRC FORM 237 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0050 EXPIRES: (MM/DD/YYYY)
(MM-YYYY) Estimated burden per response to comply with this mandatory information collection NRC MD 12.3 request: 12 minutes. This submittal is used by NRC to determine the validity of the REQUEST FOR requirements for access. Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC ACCESS AUTHORIZATION 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0050), 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
- Note: Social Security Numbers must not be visible on the outside of any package sent by mail. collection.
- 1. Date (MM/DD/YYYY)
INSTRUCTIONS: Submit original only. Detailed instructions are on the next page.
- 3. From: (Name and abbreviated organization)
- 2. To: Chief Personnel Security Branch Division of Facilities and Security Office of Administration 4. Signature (Electronic or Handwritten is acceptable)
U.S. Nuclear Regulatory Commission Washington, DC 20555-0001
- 5. Request the below named applicant(s), U.S. Citizen(s), be processed for an NRC Access Authorization as indicated:
"Q" "L" "U" "R" "SGI"
- 6. Name of Applicant (Last, First, Middle) or See attached list of applicants 7. Social Security Number (Last 4 Digits)
- 8. Remarks (Include current or former security clearances and granting agency.)
- 9. NRC Sponsoring Office or Division (See instructions) 10. Contract Number or Name of Licensee
- 11. Enclosures 12. Approval by NRC Contracting Officer Representative:
Payment (Check) if applicable A. Name and Title FD 258, Fingerprint Cards (Two copies)
NRC Form 176(A), Security Acknowledgment (For "Q" and "L" Requests)
NRC Form 176(B), Special Nuclear Material Access Authorization Acknowledgment (For "U" and "R" Requests) B. Signature Other (Specify)
C. Date (MM/DD/YYYY)
NRC FORM 237 (MM-YYYY) Page 1 of 1
NRC FORM 237 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
NRC MD 12.3 REQUEST FOR ACCESS AUTHORIZATION (Continued)
Instructions A. PURPOSE OF FORM:
This form is to be used for requesting NRC access authorizations for employees of NRC contractors, subcontractors, licensee employees, employees of other government agencies, or other individuals who are not applicants for employment with NRC. Use of this form is required by NRC Management Directive 12.3 for NRC contractors and 10 CFR Parts 11 and 25 for NRC licensees.
B. MULTIPLE REQUESTS:
A single NRC Form 237 may be used to request access authorizations for several individuals who all require the same type of access authorization (e.g., all "Qs" or all "Rs"). The individuals and their social security numbers may be listed in the remarks section or on a roster appended to the NRC Form 237.
C. WHO PREPARES THE FORM:
The agency or firm employing the individual(s) normally prepares this form (except in the case of a subcontractor, in which case the prime contractor will prepare this form). The NRC sponsoring office or division may prepare this form in the interest of expediency.
D. APPROVALS REQUIRED:
Item 4 must be signed by the agency or firm security officer (or other authorized official). If this request is in connection with an NRC contract, or anticipated contract (e.g. basic ordering agreement),
or for access authorization for licensee personnel or licensee contractor or agents, Items 9 and 10 must be completed. The request must be approved in Item 12 by NRC Contracting Officer Representatives (COR's) for contractors requiring access.
E. SUBMITTING THE REQUEST:
All requests may be submitted to the address in Item 2; however, when approval in Item 12 is required, it will avoid delay in processing if this request is submitted through the approving NRC COR. Security forms completed by the applicant(s) are to be firmly attached to this form. (For certification of an existing security clearance or federal access authorization, NRC licensee related activities should consult 10 CFR Parts 11 or 25, as appropriate, for requested forms and related procedures and fees.)
F. PRIOR INVESTIGATIONS AND SECURITY CLEARANCES:
To assist in the processing of this request, please list in Item 8 or attached roster:
- 1. Any prior investigations on the applicant(s). Give date, type (i.e., background investigation or national agency checks), and investigating agency; and
- 2. Any current or prior security clearances (i.e., access authorizations) held by the applicant(s) with NRC or any other agency. Give dates held, level (i.e., Top Secret, Secret, Confidential, "Q", "L", "U", or "R"), and agency granting clearance.
PRIVACY ACT STATEMENT NRC FORM 237 "REQUEST FOR ACCESS AUTHORIZATION" 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 237. 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 Records 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, 2201(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.O. 13526; E.O. 13587; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised; 5 CFR parts 731, 732, and authorities cited therein.
- 2. PRINCIPAL PURPOSE(S): For requesting NRC access authorizations for employees of NRC contractors, subcontractors, licensees and other government agencies, or other individuals who are not employees of or applicants for employment with the NRC.
- 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, failure to provide the requested information may result in the denial of entrance and/or access to the agency or facility and the information to which access is requested. Failure to provide the Social Security number (SSN) may delay processing. The use of the SSN is necessary to verify clearance information because of the large number of individuals who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
- 5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.