ML20005E470

Request for OMB Review & Supporting Statement Re NRC Form 443, Confidential Statement of Employment & Financial Interests. Estimated Response Burden Is 360 H

ML20005E470
Person / Time
Issue date:	12/27/1989
From:	Amenta J NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
To:
References
OMB-3150-0025, OMB-3150-25, NUDOCS 9001050290
Download: ML20005E470 (9)

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';' 'y,'*"",s3 Request for 058 RevieL gM,2g important '

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Road instructions before completing form. Do not use the same SF 83 Send three copies of this form, the material to be reviewad, and for -

f C request both an Executive Order 12291 review and approval under -

paperwork-three copies of the supporting statement, to:

. the Paperwork Peduction Act.

Answer all questions in Part 1, if this request is for review under E.0, Office of information and Regulatory Affairs 12291, compkte Part 11 and sign the regulatory certification if this Office of Management and Budget i

request b for approval under the Paperwork Reduction Act and 5 CFR Attention.' Docket Library, Room 3201 1320, skip Part 11, complete Part ill and sign the paperwork certification.

Washington, DC 20503 i

PART t,-Complete This Port for All Requests,

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- 1. Deportrnent/ agency and Bureau /of fice enginating request.

2. Agency cooe

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R Ues. Nuclear Regulatory Commission

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3. Name of person who can best answer questions regarding this request Telephone number.

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4. Tita of information collection or rulemaking 3 492-1634 i

NRC' Form 443, Confidential Statement of Employment and Financial Interests

5. Legal autnanty f or information collection or rule (cste United States Cooe. Pubhc Law, or Docutive Order)

E.O.

11222 use

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4. Affected pubhc(check allthatapply) 5 0 rederaiagenciesorempior.o.

1 O Individualsorhouseholds 3 0 rarms s O Non profitinstitutions 2 O stateoriocalgovernmer.ts 4 O Businesses or other for profit 7 O smaiibusinessesororgamz3tions PART ll.-Complete This Part Only if the Request is for OMB Review Under Executive Order 12291

7. Regulation Identifier Number (RIN) '

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. _ _ _ or, None assigned O S. Type Lf submission tcheck one on each category)

Type of renew reevented

' CleeseNcellen Stage of developonent 1 O standard 1 O uaior 1 O proposedordraft 2 O eendmg 2 O Nonmajor 2 O renalorintenmfinal.withpnorproposal 3 O Emergency 3 0 rinaiorintenm finai. witnout enor proposa:

4 0 statutoryoriudiciaidesdiine

9. CFR section affected CrR

.10. Does ins regulation contain reporting or recordkeeping requirements that require OMB approval under the Paperwork Reduction Act and $ CrR 13207 O yes ONo 11.11 a major rule,is there a regulatory impact analysis attached?

1 O yes 2 O No 3 C Yes 4 O No if"No." did OMB waive the analysis?

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Certification for Regulatory Submissions in submitting this request f or OMB review, the authonzed regulatory contact and the program official certify that the requirements of E.O.12291 and any appheable

' policy directives have been complied with.

l : Signature of program offic3!

Date l

l l Signature of authonzed regulatory contact Date 12 40htBuneonty)

Previous editions obsolete 83 108

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5 CFR 1320 and LO 12291 PDR ORG EUSOMB JI PDC ig

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v PART lil.--Complete This Part Only if the Rsi uest is for Approval of a Collection t

of information Undee t.'.e Paperwork Reduction Act and 5 CFR 1320.

.13. Abstract-oe crit-wos. unes end offected publ6c in 50 wwds or iens : " Financial. Disclosure ~ Reporting"" '

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Information is= required to determine possible employment conflict of:

interest'and determination ~of professional qualifications for NRC' consultants, cdvisers, and experts.

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14. Type of information collecten (check only one)

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> I:Jormation ce, Nect6en,e not contained M rules c

10 Regularsubmienien; " g 2 O Emergencysubmesen(certiteetionettached)

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g information senestione eenesked k mies pg ;;,

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= 30 Existingregulation(nochorpeproposed) 6 Final or interim final without prior NPRM

7. Enter date of expected or ictwel Federal. '

4 O Notice of proposets rulemakirg(NPRM)

'A-Reguler submission - -

Registerpubiicatenetthisstageof rulemsidig '

5 O Final, NPRM was prov6ously published. -

8 C, Emergency submission (certifcation attached)

. (month, day, year):_

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15. Type of review requestedcheckimly'one)

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' 1 O New coiiection:

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4 O Reinstatement of a previousiy approved coiiection for which approvet ;~i-2 O Revisma of a Wrrente 'eperoved coiiection h*' 'd r

30 Extension of the expiration date of a currently approved collertion 5 O Existing collecten in use without an oMB controi number without any chage in the substance or in the method of col'ecten

16. Agency report form number (s)(include standard /bptenal form number (s))

22. Purpose of information coilection (check as inany as apply)

NRC 443 1 @ Appiscation for benefits 2 O Pr%1 ram evaluation

17. Annuet reporting or disclosure burden 3 0 ceneraipurposestatetics 1 Number of respondents,

'lA0 4 @ Regulatoryorcompliance 2 Number of responses per respondent I

5 O Programplanningormanagement 3 Total annual responses (fine i times line 2) 180 6 O Research

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4 Hours per response],. _.....~....

2

' 7'O ' Audit 5 Total hours (Ime 3 times' tine 4) 360

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23. Frequency of recordkeeping or reportmg(check aff that appfy)

18. Annuairecordkeepingburden.

E I Number of rocordkeepers......

10 Recordkeeping 2 Annual hours per recordkeeper, ReportM 3 Total recordkeeping hours (hne 2 tsmos line 2) 2 @ Onoccasion 4 Recordkeeping retention period years 3 0 visekiy

19. Total onnual burden 2 8 -

4 O Montniy 1 Requested (line 27 5 plus tind 18 3).

360 5 0 overterty 2 tn current OMB inventory 360 6 0 semi annuaiiy 3 Difference (Iine 1 Jess line 2) 0 7 O Annuaiiy Explanation of detterence 8 O Beennisily 9 0 otner(descnoe):

4 Program change

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5 Adjustment.

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1 O Voluntary

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21. Requestad expiration date gg _

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2 O Required to obtain or retain a benefit 10/31/92. c h~

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s O uandatory

25. Arete respondents primanly educational agencies or institutions or is the pnmary purpose of the collection related to Federal education programs? O yes @ No

26. Does the agency use sampling to select respondents or does the agency recommend or prescribe the use of sampling of statistical analysis m

.... O Yes a No by respondents?

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27. Regulatory authonty for the mformaten collecten a-10 CFR 0.735-28(a)

or FR

or.Other(specify)

Paperwork Certification in submitting this request for OMB approval. the agency head. the senior official or an authorized representative, certifies that the requirements of 5 CFR 1320 the Privacy Act, statistical standards or directives, and any other applicable information poley directives have been comphed with.

Signature of program official, Date l

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l Sign.tt,ure of agency need, the senior offciai or an autnonzed representati e Date l

Joyce A. Amenta, Designated Seni Officia for l

Information Resources Manacrement-Me t k

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I M GPO 1984 0 - 453-776

t OMB SUPPORTING STATEMENT FOR NRC FORM 443 CONFIDENTIAL STATEMENT OF EMPLOYMENT AND FINANCIAL INTERESTS 10 CFR PART 0.735-28 Description of the Information Collection NRC Form 443 requires approximately 180 individuals-a year to submit a resume of their employment and professional achievements,

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and a confidential record of their financial interests.

Individuals submit thie form prior to commencement of NRC employment and every May thereafter for renewal of their appointment.

A.

JUSTIFICATION 1.

Need for the Collection of Information.

Paragraph 0.735-28(a).of 10 CFR Part 0 provides that certain NRC consultants, advisers, and experts (defined as "Special Government Employees," 10 CFR 0.735-4 (e)) shall submit statements of employment and financial interests prepared in accordance with 10 CFR.O.735-28(c).

The information is furnished on NRC Form 443.

These individuals are required to complete NRC Form 443 because submission of these financial statements is mandated.by Executive Order 11222 (May 8, 1965).

2.

Agency Use of Information.

NRC Form 443 provides the staff with (a) a resume of-the individual's employment and professional achievements, and (b) a confidential record of financial interests for use in judging possible conflicts of interests.

This information is necessary if potential conflicts of interest are to be assessed.

It also provides hiring officials with a basis for determining the qualifications of the consultant, adviser, or expert, and for setting the appropriate rate of compensation.

3.

Reduction of Burden Through Information Technology.

There are no legal obstacles to reducing the burden associated with this information collection; however, technical difficulties prevent reducing the burden below its current level.

To our knowledge, no automated L

systems exist that deal with this sort of information.

4.

Effort to Identify Duplication.

NRC Form 443 does not duplicate or overlap other information collected by the NPC or other government agencies.

5.

Effort to Use similar Information.

There is no similar information compiled.

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6.

' Effort to Reduce Small Business' Burden.

This form-requires a small expenditure of time and effort.

It is i

not possible to reduce the burden on small businesses by less frequent or less complete reporting requirements.

7.

Consequences of Less Frequent Collection.

If the requested information is collected less frequently, potential conflicts of interest might go undetected.

8.

Circumstances Which Justifv Variation'From OMB Guidelines.

Not applicable.

9.

Consultations Outside the NRC.

None.

This form has been in use for many years.

10.

Confidentiality of Information.. Confidentiality is required by E.O. 11222.

This information is used for internal purposes only.

However, information may be transmitted to the Department of Justice if it could provide a basis for criminal prosecution.

11.. Juctification for Sensitive Questions.

There are no alternatives for collecting this information.

Financial and employment information is the only means of determining conflicts of interests.

Confidentiality pledges are expressed on the form itself in the title and at the end.

12.

Estimated Annualized Cost to the Federal-Government.

.The collection of information will require an average of two hours of NRC staff time per report.

For 180 respondents, the collection will require 360 hours0.00417 days <br />0.1 hours <br />5.952381e-4 weeks <br />1.3698e-4 months <br /> per year (2 hr./ report x 180 reports / year).

Annual labor cost at $95 per staff hour will be $34,200.

The estimate of labor cost is based on diccussions with personnel in the Office of the General Counsel who process these forms.

13.

Estimate of Burden, a.

The estimated annual burden for this information collection is approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> per year.

Total industry burden is 360 hours0.00417 days <br />0.1 hours <br />5.952381e-4 weeks <br />1.3698e-4 months <br /> (2 hrs x 180 responses = 360).

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Estimated annual cost per respondent is $190

($95/hr x 2 hrs.).

Total annual industry cost is

$34,200.

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14.

Reasons for Change ~1n-Burden.

Durden remains the same.

15.

Publication for Statistical Use.

None.

16.

Collection =of Information Employing Statistical Methods.

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Statistical methods are not used,in the collection of information.-

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UNITED stATW NUCLEAR,RSSULATORY COMMIS$10N men. e,

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. MiCONFIDENTIAL STATEMENT OP EMPLOYMENT,-

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. AND, FINANCIAL.1NTERESTSw

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PAPT A 1 NAME (First. m6edte initiet. leet)

2. SIRTH DATE.

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3. HOME ADDRESS (Street. City, State. IIP Codel

4. TE LEPHONE:-

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6. COLLEGE OR UNIVE R$1TY

17. DATES ATTENDED

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10. e if you are a U.S. Civil Servme annuitant.

b. Are you a retired offar of a repler component of the Uniformed Servces?

what a your monthly annuity?

t yer If yes contact your Service for information coneeming any reduction in retired military pay made neccesery by receipt of Federal civilian pay, g

}11. Employment during test 10 years 6actu, sing seneuttentehese). List present position first - vou nees instues en6y the ones teented to your,eguler p Lkt current steeleret reeltJene in inom i2, below.

EMPLOYER AND ADDRESS POSITION HE LD,

SALARY OR FEE l DATES t

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12. OTHER FEDERAL GOVERNMENT EMPLOYMENT. List all other Federaldepartments and egencies (including other NRC offices)in whch you are serving or expect to serve as consultant adviser, expert, or part. time, or intermittent employee during the next 365 days. If none, wnte "None."

TITLE OR l

APPOINTMENT PERIOD l 'ESTIM A'YET

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NO OF AGENCY AND LOCATION KIND OF POSITION FROM TO DAYS

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PART S - CONFIDENTIAL STATEMENT OF EldPL*.YMENT AND FINANCIAL INTERESTS -

14c NAME w irst, middle leasel, leetlt

'14.b BUSINEI3 ADDRESS ICity, Std j

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15.. CURRENT NON FEDE.RAL EMPLOYMENT. List all corporations, compemes firms, or other tiuseness enterpreses, partnerships, non profit organi:ewns.

4 E and eduestionel, or other institutione, including State orlocalgovernmentalorganiastions:(el with which you, your spoues, or minor children are connected l

.J as en employee, officer, owner, director, memtier, trustee, partner, adviser,or sonounent, with or without componestion; or (b) in euhich you, your spouse,-

tM minor children heiro any continuing financial interests, through a pension or rfttroment plan, shared income, of other arrangement se a result of any -

current or prior employment or business or professional association. Repest information on present employment recorood in item 11 on page 1.'

If none, write None."

"4' NAME AND KINDOF ORGANIZATION (e.A manufacturmg, research, inweencel -

___._ LOCATION. ~..

TI.TLE OR. KIN..D. OF PostTION..

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3 116. FINANCIAL INTERESTS. List your investments and, to your knowledge, thoes of your wouse, minor children.ond blood rosations who are fun.teme residents of your household. If none, write "None." Ypu need not list holdmgs m Feogrel bonds or those fmancial interests whech are, as of the dote of this statement is submrtted, enempted under Part il (@ 0.735 21(c) of NRC Appendix 4124, " Conduct of Employees." (See instructions, item 16.) You l;i

. need not revent at this time the precise amount of mvestments listed, however, you may later be required to do so if necessary for en egency, i

determination under NRC Appendia 4124 410 CFR 0.7354 I

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a. NAME OF ORGANIZATION KIND OF ORGANIZATION 1 NATURE OF INTEREST AND-IN WHOSE NAME HELD

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y y INFORMATION ON FIN ANCIAL INTERESTS REQUESTED OF OTHER PERSONS. If any mformation is to be supplied by oth b.

j trustee, attorney, accountant, or relative, please complete the bones below. 4f none, write None."

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- NATURE OF SUBJECT MA_TT.ER_.l.

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I certify th.t the above statements made by me are true, complete and correct to tne best of my knowiedge and beleet. I believe that at this tir e there i does not enest any conflict, as described in 10 CFR Part 0," Conduct of Employees," between my private interests tincluding stock.ho:dmesi and my l

Eroposed services for the NRC. I f urther expect and mtend to avoid such confiscts durmg any periods of appomtment by the NRC. I understand that.

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during the period of my apoomtment,4 must notify the NRC. m accordance with the mstructions on Page 4 of this form, of any cnange m the information under items 16 and 16. above.

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I lines reviewenigh, e sess.em. _e.n.t of_t.h.si.oM inslividusi h reist,lon so,his/her proposes sluties ensi responelbilities ed finst:

e no confHet er amt sentiist of interest.

the following question (s) which require resolution:

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The following' steps have been taken to resolve the nuestion(s) referred to above:

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under esplicette lew' and NRC regulatlene, the Indiv6 delle not to porticipate in any port 6euter metter the outeome of wh6ch will hows e direct and l'.

predistetWe offset upon the finenelei intereste of a businese enttty, including nonprofit orgentention er en eeuset6enel inetMutton, by whleh he/she le - L empleved or w4th w%4eh he/she le negottetlne for er hee any arrangement eeneern6ng pressesttwo employment, or to which he/she renders consultent R

servases, or in which he/she hee a finene.at Intemet not enemptes uneler Port 11 ($0.735 21(ell, of NRC Appendia 41

' l peelvessi from rendereng genovel envies in situottee where no preference or edentage over others might be gelned by any partleuler person or

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19. DETERMINATION SY COUNSELOR (OR DEPUTY COUN8ELOR):

I have reviewed the statement of the subiect individual and the operating offacial's determinatron above and find:

i rio evidence of conflict or apparent conflict of interest.

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1%'Vi 9 The following steps have bee'1 taken to resolve the cuestion(s) referred to above:

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m-GIGNWuH C bME The information to be furnished in items 15-16 of this statement is required by E mecutive Order 11222 and the requietions of the Office of Personnel Menegement and the Nuclear Reoulatory Commission issued thereunder, and may not be disctooed by the NRC except in es.cordance with the provisions of NRC Manuel Chaoter 4124 or as the Office of Personnel Management or the Nucieer Re0ulatory Commission may determine for good cause shown.

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INSTRUCTIONS

~ GENERAL: Propero this statement in dupleste. Submit one completed copy to the heed of the NRC division or office by which yov will be emp6cyod. Retain one copy for your files. If odditional pages are used,6dentify them by reference to the appropriate nummered item and ettech them hereto. If addit 6cnel pogos are required, information re6etmg to items 15 and 16 must be listed on a seperate page.

ITEMS:

12. Include the names of any other Federal departments or agencies. meluding other NRC of fices. with which you are affihated or expect to be durmg the nex t 365 days as consultant, adviser, expert, parvtime. or mtermittent employee. In determmmg the estimated num-ber of days service, e part of a day should be counted as a full day and a Saturday, Sunday or hohday on which duty has been or is expected to be performed, should be counted as a work day.

.15. You need not submit any mformation relatmg to your connection with, or mterest m, e professional society or a charitable, religious.

& social, tratemel, recreation, pubhc service, civic, or pohtical organization or any similar organization not conducted as a busmess 16 enteronse, and which is not engaged m the onmership or conduct of a busmess enterprise. Educational and other msistutions do.

ing research and development or related work mvohrmg grants of money from or contracts witn the Government are ocemed " bus-ness enterprises" and should be included herem.

16a. In the event any of the required mf ormation, mcludmg holdings in trust,is not known to you but is known to another person, you j

& should request that person to submit on your behalf the mformation called for under item 16a Report such reauest m item 16b The

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16tx Nuclear Reguletory Commission, pursuant to Section 208tol of the conflict of interest statute (Pubhc Law 87 849), exernated cer, tam fmancialinterests from the application of Section 200(a) of that statute (see Appendix 4124,11116 0 735 2f tcl I. "E xemption of remote or mcomeouential fmancial irterests"L You need not hst under item 16 those interests which, as of the date that state ment is submitted, are exempted under Appendix 4124, il (n 0,735 21tc) i SUPPLEMENTARY ST ATEMENTS:

Each year you sie roovired to submit a new statement. The form to be used will be provioed to you by the NRC et the appro-priate time. In addition, whenever you ecovire a fmencial mterest not listed on this form m an entity engaged in activities regu-lated by the NRC, you should promptly repo t your interest to the head of the NRC division or office that empeoys you.

PRIVACY ACT STATEMENT Pursuant to 5 U.S.C 552a (el (3), enacted into law by section 3 of the Privacy Act of 1974 (Pubhc Law 93 579), the followmg state-mont is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form 443. This mformation i

is memtemed in a system of records designated as NRC4 and described at 40 Federal Register 45334 (October 1,1975).

i 1 AUTHORITY: 18 U.S.C.201,208,and Executive Order 11222 dated May 8,1965.

2. FRINCIPAL PURPOSEISI: To allow the Nuclear Regulatory Commission,its counselor, or deputy counselors to determine whether employee's financial interests or non Governmentet employment might mvolve them m actual or potential conflicts of mterest under opphceole Federet laws, Of fice of Personnel Management or NRC Reguistions, and/or Executive Orders.

3. ROUTINE USES: To provide the Department of Justice and the Of fice of Personnel Management with information concernmg en employee in instances where this office has reason to believe e Federallaw may have been vioisted or where this office desires the advice of the Department, or the Office of Personnel Management concernmg potential violations of Federet tow; and to serve as evioence in any court or Office of Personnel Management proceedmg or m any NRC proceeding, adludication or other determina.

tion.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING l

INFORMATION: Disclosure of the reauested information is mandatory for employees of the NRC as stated m 10 CFR 0.735 28.

Feiture to disclose the reauested information or en omission m the execution of the statement may result m appropriate aammis-tretive action 6n accordance with NRC Menegement Directives System Chapter 4171.

5. SYSTEM MANAGERIS) AND ADDRESS: General Counsel. Of fice of the Generen Counset U.S. Nuclear Regulatory Commission Washmgton. O C. 20555 FOR NRC USE Instructions to the operstmg official responsible for the sopointment of this consultant. adviser. or expert:

1. Detach page no.12 (Background Statementi of NRC Form 443. Retam one copy of page 1-2 and send tne other copy to the personnel office with 3 cop.es of completed NRC Form 448.

2, Make the determmation m item 18 on page no. 3 in accordance with provisions of Append x 4tM and send page no. 34 to the designated counesior with copy of completed NRC Form 448.

3. Do not reproduce or retain e copy of pees 34.

NRC FOMr 443 (1 10 )

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