ML20209G707
| ML20209G707 | |
| Person / Time | |
|---|---|
| Issue date: | 09/10/1986 |
| From: | Norry P NRC OFFICE OF ADMINISTRATION (ADM) |
| To: | |
| References | |
| OMB-3150-0025, OMB-3150-25, NUDOCS 8609150057 | |
| Download: ML20209G707 (9) | |
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of tice of Information and Regulatory Affairs 1229I. complete Part if anit sr.n the regulatory certif: cat.on if this Office of Management and Budget request is for approvai under the Paperwork Reduction Act ana 5 CFR Attention: Docket Library, Room 3201 1320. t kip Nt it, u;mpote Pet ill a,d sign the paperwork cert.f tcaticn Wash,ngton, DC 20503 PAR T l.-Complete This Part for All Requests.
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- n. Abst ao-wee ueos mesa,dattecrea nusc en sa eso~s " Financial disclosure reporting" Information is required to determine possible employment conflict of interest and determination of professional qualifications, i
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- 23. Frmum of recardbeeping or reporting (check all thatapply)
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- 25. Are the respondents primar.ly edacahonal agenc es or insututions or is the pomary aurrase M Se conection related to Federai education p<ce.rns' C Yes {Xl No
- 26. Does tne agen use sampting to select respondents or dces tr'e ageny recomy vi or3e5rce the use of samphng or stat.stical ara ysis r
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L1 submittmg this re 4uest for OMB approval. tt'e agency hea0. the senent et*oas or an authonted represertatrve, certif es that the requ,rements at 5 CF H 1320. the Privaq Act, stat sticai standards or d.rectnes, and any ott'er apphcable mformatan rohcy direct,ves have tren compi.ed with.
Signature or p rca ettcar j Date S.gnature of a eQead. f t.e senior off oat or an authonzed representatn,e
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Patricia G. Norry, Director Office of Administration C8 l
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4 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, and a confidential record of their financial interests. -Individuals submit this form prior to commencement of URC 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 O 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 finan-cial interests prepared in accordance with 10 CFR 0.735-28 (c).
The information is furnished on NRC Form 443.
These indi.viduals 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 inter-ests.
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 Durden Throuch 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.
No automated systems exist, to our knowledge, that deal with this sort of information.
2 4.
Effort to Identify Duplication, NRC Form 443 does not duplicate or overlap other information collected by the NRC or other government agencies.
5.
Effort to Use Similar Information.
There is no similar information compiled.
6.
Effort to Reduce Small Business Burden.
This form requires a small expenditure of time and effort.
It is 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 frequent-ly, potential conflicts of interest might go undetected.
8.
Circumstances Which Justify 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.
The information, however, may be transmitted to the Department of Justice if it may provide a basis for criminal prosecution.
11.
Justification for Sensitive Questions.
There are no a3ternatives for collecting this information.
Financial and employment information is the only means of determining conflicts of interests.
Confidentiality pledges are c>: press en the form itself in the title and at the end.
12.
Estimated Annualized Cost to the Federal Govern-ment.
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 /yeat.)
Annual labor cost at $60 per staff hour will be $21,600.
The estimate'of labor cost is based on discussions with personnel in the Office of the General Counsel who process these forms.
3 13.
Estimate of Burdens.
a.
The estimated annual burden for this informa-tion 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 />.
b.
Estimated annual cost per respondent is $120
($60/hr x 2 hrs.).
Total annual industry cost is $21,600.
1 14.
Reasons for Change in Burden.
Slight variations occur from year to year in the number of consul-tants the agency has to hire.
15.
Publication for Statistical Use.
None.
16.
Collections of Information Employing Statistical Methods.
Statistical methods are not used in the collection of information.
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NRC Form 443 UNITED STATES NUCLEAR REGULATORY COMMISSION Approwd ly OM8
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(i 4 28 CONFIDENTIAL STATEMENT OF EMPLOYMENT sis m 2s i CFR a33 28 AND FINANCIAL INTERESTS (Consulttnts below pay rate of GG.16 or who work less than 60 days a year)
PART A
- 1. N AME (First, middle initial, last)
- 2. BIRTH DATE
- 3. HOME ADDRESS (Street, City State, ZIP Code)
- 4. TE LE prion E:
Home:
Business:
- 5. Citgen 6 COLLEGE OR UNIVERSITY
- 7. DATES ATTENDED
- 8. D EG R E E
- 9. YE AR of U S A O YES O NO
- 10. a f f you are a U.S. C iv il Service annuitant, what is you r rnonthly annuity ? S.................................................
- b. Are you a retired of ficer of a regular component of the Uniformed Services?
Yes O No If yes contact your Service for infonnation concerning any reduction in retired rdletary pay made necessary by receipt of Federal civihan pay.
- 11. Employment during last 10 years (including consultantshipst List present position first - you need include only the ones related to your regular p'rofession. List current Federalpositions in item 12, below.
EMPLOYER ADDR ESS POSITION HELD SALARY OR FEE DATES
- 12. OTHE A FEDE RAL GOVERNMENT EMPLOYMEN T. List aft other Federal departments and agencies (including other NRC offices) in which you are serving or rupect to serve as consultant. adviser, expert, or part time, or intermittent employee during the next 365 days if none, write "None "
APPOINTMENT PERIOD ESM ATE D AGENCY AND LOCATION TITLE OR KIND OF POSITION NO.OF FROM TO DAYS 13 List you. s gmficant professional society rnemberships. nonnrs, and fellowsh.ps received, important pubhcations, licenses, and other speCialQuah fiCations:
I
PART B -CONFIDENTI AL STATEMENT OF EMPLOYMENT AND FINANCIAL INTERESTS 14 a. N AME (First, middle initial, last) 14.b. BUSINESS ADDRESS (City, State)
- 15. CURRENT NON FEDER AL EMPLOYMENT. List all corporations, companies, firms, or other business enterprises, partnerships, non-profit organizations, and educational, or other institutions, including State or local governmental organizations: (a) with which you, your spouse, or minor children are connected as an employee, officer, owner, director, member, trustee, partner, adviser,or consultant, with or without compensation; or (b) in which you, your spouse, or minor children have any continuing financial in-terests, through a pension or retirement plan, shared income,or other arrangement as a result of any current or prior employment or business or professional association. Repeat information on present employment recorded in item 11 on page 1. If none, write "None/*
NAME AND KIND OF ORGANIZATION LOCATION TITLE OR KIND OF POSITION (e g., manufacturing, research, insurance)
- 16. FINANCIAL INTERESTS. List your investments and, to your knowledge, thoes of your spouse, minor children, and blood role-tions who are full-time residents of your household. If none, write "None!' You need not list holdings in Federal bonds or those financial interests which are, as of the date of this statement is submitted, exempted under Part II ( 0.735-21(c) of NRC Appen-dix 4124, " Conduct of Employees." (See Instructions, item 16.) You need not reveal et this time the precise amount of invest.
ments listed, however, you may later be required to do so if necessary for an agency determination under NRC Appendix 4124 (10 CF R O.735).
N ATU R E NTEREST AND a NAME OF ORGANIZATION KIND OF ORGANIZATION b.
INFORMATION ON FINANCIAL INTERESTS REQUESTED OF OTHER PERSONS. If any information is to be supplied by other persons, e g., trustee, attorney, accountant, or relative, please complete the boxes below. If none, write "None."
NAME AND ADDRESS DATE OF REQUEST NATURE OF SUBJECT MATTER f
17, I certify that the above statements made by me are true, complete and correct to the best of my knowledge and belief. I believe that at this time there does not exist any conflict, as described in 10 CFR Part 0," Conduct of Employees /* between my private interests (including stock-holdings) and my proposed services for the NRC. I further expect and intend to avoid such conflicts during any periods of appointment by the NRC. I understand that,during the period of my appointment, I must notify the NRC, in accordance with the instructions on Page 4 of this form, of any change in the information under items 16 and 16, above.
(Signature)
(Date)
NRC Form 443 (1,82) 2
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- 18. DETERMINATION BY APPROPRIATE SUPERVISORY OFFICIAL:
I have reviewed the statement of the subject individual in relation to his/her proposed duties and responsibilities and find:
O no conthet or apparent confi.ct of mterest.
O the foitowing question (s) which requ e resolution:
The following steps have been taken to resolve the question (s) referred to above:
Under applicable law and NRC regulations, the individualis not to participate in any particular netter the outcome of which will have a direct and predictable effect upon the financial interests of a business entity, including nonprofit organization or an educational institution, by which he/she is employed or with which he/she is negotiating for or has any arrangement concerning prosNtive em-ployment, or to which he/she renders consultant services, or in which he/she has e financial interest not exempted under Part it (
0.735-21(c)), of NRC Appendis 4124. However, he/she need not be precluded from rendering general advice in situations where no preference or advantage over others might be gained by any particular person or organization.
(Signature)
(Date)
- 19. DETERMINATION BY COUNSELOR (OR DEPUTY COUNSELORl:
I have reviewed the statement of the subject individual and the operating official's determination above and find:
O no evidence of conflict or apparent conflict of interest.
O the following question (s) which required resolution:
The following steps have been taken to resolve the question (s) referred to above:
(Signature)
(Date)
The information to be furnished in items 15-16 of this statementis required by E xecutive Order 11222 and the regulations of the Office of Personnel Management and the Nuclear Regulatory Commission issued thereunder, and may not be disclosed by the NRC except in accordance with the provisions of NRC Manual Chapter 4124 or as the Office of Personnel Management er the Nuclear Regulatory Commission may determine for good cause shown.
NRC Form 443 (142) 3
INSTRUCTIONS GENERAL: Prepare this statement in duplicate. Submit one completed copy to the head of the NRC division or office by which you will be employed. Retain one copy for your files. If additiona pages are used, identify them by reference to the r
appropriate numbered item and attach them hereto. If additional pages are required, information relating to items 15 and 16 must be listed on a separate page.
ITEMS:
- 12. Include the names of any other Federal departments or agencies including other NRC of faces, with which you are affshated or expect i
to be during the nem t 365 days as consultant, adviser, enpert. part time c>r interrmttent employee in determinirig the estimated num-ber of days service, a part of a day should be counted as a full day and a $dtarcay. Sanday or hohday on which duty has been or is expected to be performed, should be counted as a work day
- 15. You need not si b mt any information relating to your connection with, or interest in, a professional society or a charitable. rehgeous,
& social, fratemal, recreation, public service, civic, or pohtical organization or an r s.mitar organ.zation not conducted as a business
- 16. enterpnse, and which is not engaged in the ownership or conduct of a busentass erteror.se. Educationat.nd other institutions do ing research and development or related work involving grants of money from or contracts witn the Government are deemed " bus ness enterprises" and should be inclu Jed herein.
16a. fn the event any of the required information, including holdings in trust. is not snown to you but is known to another person you
& should request that person to submit on your behalf the information called for # der item 16a Peport such request in stem 16b The 16b. Nuclear Regulatory Commission pursuant to Section 208(b) of the conthct of 'terest statute IPubhc Law 8 7 849L exemuted cer tain financial interests from the apphcation of Section 208(a) of that statute ve Ance-der 4124. Il f f 0 735 21(c) 1. " Exemption of remote or enconsequential financial interests") You need not hst under.te-16 those enterests which as of the date that state ment is submitted, are exempted under Appendix 4124. Il i s 0 735 21tc) )
SUPPLEMENTARY STATEMENTS:
Each year you are required to submit a new statement. The form to be used will be provided to you by the NRC at the appro-priate time. In addition, whenever you acquire a financial interest not hsted on this form in an entity engaged in activities regu-lated by the NRC, you should promptly report your interest to the head of the NRC division or of fice that employs you PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552a (e) (3), enacted into law by section 3 of the Privacy Act of 1974 (Pubhc Law 93-579), the following state,
i ment is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form 443. This information is maintained in a system of records designated as NRC 4 and described at 40 Federal Register 45334 (October 1,1975).
- 1. AUTHORITY: 18 U.S.C.201,208,and Executive Order 11222 dated May 8.1965.
- 2. PRINCIPAL PURPOSE (SI: To allow the Nuclear Regulatory Comm;ssion,its counselor, or deputy counselorsto determinewhether employee's fmancial interests or non Governmental employment rtight involve them in actual or potential confhets of interest under applicable Federallaws, Of fice of Personnel Management or NRC Regulations, and/or Executive Orders.
- 3. ROUTINE USES: To provide the Department of Justice and the Office of Personnel Management with information concerning an employee in instances where this office has reason to be4ieve a Federallaw may have been violated or where this office desires the advice of the Department, or the Office of Personnel Management concermng potential violations of Federal law; and to serve as evidence in any court or Office of Personnel Management proceeding or in any NRC proceeding. ad udication or other determina-tion.
4 WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosure of the requested information is mandatory for employees of the NRC as stated in 10 CFR 0.735-28.
Failure to disclose the requested information or an omission in the execution of the statement may result in appropriate adminis-trative action in accordance with NRC Management Directives System Chapter 4171.
- 5. SYSTEM MANAGER (S) AND ADDRESS: General Counsel. Of fice of the General Counsel U.S. Nuclear Regulatory Commission Washington, D.C. 20555 i
FOR NRC USE instructions to the operating of ficial responsible for the appointment of this consultant, adviser, or expert:
- 1. Detach page no.12 (Background Statement) of NRC Form 443. Retain one copy of page 12 and send th'e other copy to the personnel office with 3 copies of completed NRC Form 448.
- 2. Make the determination in item 18 on page no. 3 in accordance with provisions of Appendix 4124 and send page no. 3 4 to the designated counselor with copy of completed NRC Form 448.
- 3. Do not repro' uce or retain a copy of page 34.
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