ML20247Q984
| ML20247Q984 | |
| Person / Time | |
|---|---|
| Issue date: | 05/26/1989 |
| From: | Amenta J NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| To: | |
| References | |
| OMB-3150-0005, OMB-3150-5, NUDOCS 8906070103 | |
| Download: ML20247Q984 (8) | |
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Request for OMB Review
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!Importent:
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Send three copies of this fort ne idaterial to be reviewed, and for Read irMructions before completing form. Do not'use the same SF 83 t
to request both an Executne Order 12291 review.and approval under paperwork--three copies of the supportirp statement,to.
the Papetwork Reduction Act.
n Answer all questions in Part 1. If this request is for review under E O.
Office of information and Regulatory Affairs '
E12291, complete Part !! and sign the regulatory certification. If this :
Office of Management and Budget request.is for approval under the Paperwork Reduction Act and 5 CFR Attention: Docket Library, Room 3201 L 1320, skp Fa rt II. comp;ete Pa.t til and sign the paperwork certification.
Washington. DC 20503 L PART 4.-Complete This Part for All Requests.
.1. Department / agency and Bureau /of bce orq; ratFE reCuest
- 2. Agency coce.
..U.S[NuclearRegulatory' Commission
'3
, l' 5-0
. 3. Name of person wno can best answer questions regardert this request Telephone numoer
.JL._G._. Br_cok s (3.01 ) 492.3138 L 4. litie of rit0rr9atton cotieClion or rufe?akirip
[NRC' Form 4, Occupational External Radiation Exposure History 5., Lepi euthonty for iriormatson wiect.an or rve (c.te Umtec Ststes Code. Pabhc Law. or Enecatrue Orner) 42 use_2201_(ol or fL Affecteo pubhc # neck a7l thaf app />>
'S O Federalegencies or employees l
1 O.ndividsa!s or noesehen i O rarms s O Non-protitinstitutions 2 C State or tocaigovernmenu 4 $ Busarresses or other for. profit 7 C Smanbusinessesororganizatcons PART ll.-Oomplete This Pari Only if the Request is for OMB Review Under Executive Order 12291
- 7. Regulation Icentifier Namber {RtN)
_. _ _ _, or, None assigned C l.' ~. lype o suomnss;on f check one m eacn ca'egory)
Type of review requested 8
s Clustrication Stage of development 1_O stancarc 1 O ukor -
2 O proposed or dratt 2 O rendmg 2 O Nonmajor 2 O rmaiormterimienai.withonorproposai 3 0 cmercency 3 C rinal or intenm final. w thout pnor proposal 4 U Statutory or judicial deadhne l
- 9. Cf R sectior; attected CFR
.10. Does th s r n ' on ccintam repert.ng or ecordbeeprng reamrements that recuire OMB approval under the Paperwo% Reduction Act
. C yes C No and 5 CFR.
- 7 ?
l 1 O Yes 2 C No '
' 11. ft a major rue is there a reg Atory impe:t analyps cttached?
3 C Yes 4 O No Elf"No."d4d OMB eaive the anafA7 Cert!fication for. Regulatory Submissions in subrn.thng this request f or OMB review the authonzed reguistory contact and the per> gram official certsiy that the requirements of E.O.12291 and any appbcable po. icy dire twer, have been cor pried with Date J Sgnature of program officesi Signature of autnoniec regulatory co%:t Date 8906070103 890526 PDR ORG EUSOMB~
12.(oms use onry; PDC standard rorm 83 (Rev 9 63)
Prenous edrtes obseicte 83 108 Prestnhed ty OMB NSN 7540 00 634 40.14 5 CFR 1320 and E O 12231 l,
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e Pf.RT fil/-C:mpleta This PartCaly if the Requ:st is f:r Appr:vtlci a C:llictlin of Information Under the Paperwork Reduction Act and 5 CFR 1320.
- 2. Aest an-oes:nb. reeds usesandaffectedpubncinsowordsoriess. " Nuclear Radiation Monitoring, Radiation Exposure"'
~ NRC Form 4 is.used to record the occupational exposures of individuals to ensure that the accumulated = exposure does not exceed regulatory limits.
- 14. 'ga of 1 iformation col:ection (ct:eck only one)
Information collections not containedin rules 1 C Pegular subrmssion,
2 C Eme gency submission (cernt, cat,on at' acred /
I tformation collectlena containedin rules J 3 E E.usting regulation (nochangeproposed) 6 Fmal or intenm final mthout prior NPRM
- 7. Enter date of expected or actua: Federal 4
tiotice et proposed ruiemaking(NPRY)
A C Pegular submission Register puDhcstion at tbs stage of rulemakmg i U hr:al.?JF.M was prerously pubbshed B C Emergency subm'ssion (certificetton at! acned)
(mcof', J81. year) i h pe of rev'tw reovested (check only one) 2 C New col'ect:or.
4 C Reinstatement of a previously approved cotiecton +or which approvsf -
' "P#
,2 2 Eevisicn of a currently approved collection
' 3 b Extensio9 of tre expiration date of a currently approved collection 5 C Ea'stieg cokection in use mthout an OMB control rurnber et90.;t ary c*arige m tre substance o'in the rnethod of collection
.. Me" \\ report fo"1 riurrber(s)(anclude standard /optior'al forrn nurnber(s))
- 22. Purpose of nformat:on coHect o-(check as raany cs.spoly)
- U # # *""' " "'
NRC Form 4 2 C P ogram eva. cat-on
'. er Sa 'ecott-g or tsclosure burden 3 C Geaer# purpose statates 41 Regulatory o comphaate
. Ireer of 'espondents.
2. -te* Of <esco ses per respondent.
5 C Prog sm plawg or' avgement
- 1 Na ra"W escorses /He ! +;tmes hr e 2) 6 C Resea ch 7 C Aud't
. -nes re esco,se S W mo,, s w e.e senes une 4) l 1
n
[d. 7:a* eco c*etoirg curden
- 23. Frecuency of recordneep rg or reporting (eneen an tear app y) 7.575 2 2 Reco,d.eep,ng
! %.-ber cf recordkecoers 1.3
- seportin,
. Ma' %rs per ece ; keeper.
3 htsi eced.e6 ping hours (tine 1 tirnes line 2) 10.000 2
on occasion a Recedkeepirg retent.on oenod Lifetime years 3 C we.ey
- P. b l m a'carde" 4 C Mont-Cy 10.000 5 C qu,rten,
- 2,,,,,.,d gr.,2 7 3 pru, nn,2 sa).
7.500 6 C semsan%any 2 * :eent oMB Wertory
+ 2.500 7C Anedy 2 :.t+erea:e ve l 'ess ime 2)
Op avatkn of oderer.ce 8 C Brenn.any
- P : ram :targe 9 C otner(destroe)
+ Z A00
_ n.yent l
M.."* t +sheccat)cMB controi number or comment number
- 24. Responder.ts' obi.getion to comoth'chec A 'he 5 fro *feSi oc'Est.or thaf spps,es) 3150-0005 1 C voiu ta y g
l-
- 9. N Me: ec rate cate 2 C Recurred to cota.n er reta r a tenefit 4/30/92 3 10 uanoces
- s;nce95 prer anly educat'onal agencies or institutions or is the primary purpze of tre collection re:ated to Fe:eral educ.3t.on p'cgraM C Ye db( 6 ** e 4e9:y use samplingto sciect respondents or does the agency recomr end or Drescr.be the use of samp ag or statist' cal are ysis Cyes $ No 3 emr;cerdst 2)T*57s a o y a.anor4 for the information collection
_10 crR Part 20
- or rR or. Other (speedy)
% e m Certification g tEs e. est *cr oVB approvat. tne agency head, the senior off.:.al o an authonred represertatu ;e *> es t' 9' **.e revec e.ts of 5 CA 13:o. '*e
.x.mT tct staNar:'s or directives, and any other appl'cacie information pot.cy d>rectwes have ter comosed e jOve
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.L OMB SUPPORTING. STATEMENT FOR NRC FORM 4 OCCUPATIONAL RADIATION EXPOSURE HISTORY Description ofLthe Information Collection 10 CFR Part 20, Section 20.102, " Determination of. Prior Dose," requires licensees to record the prior occupational exposure history of certain individuals:in order to assure that the individuals' total occupational doses do not exceed the-radiation dose limits for individuals in restricted areas (620.101).
NRC Form 4, or its equivalent, is used for recording the'exp.'sure information for prior employments. The form shows each period in'which the individual received occupational exposure and is signed by. the individual that-received the exposure.
A.
JUSTIFICATION
- 1.
Need for the Collection of Information In order to' protect the health and safety of workers, 10 CFR Part 20 requires licensees.to control within specified limits the total. occupational radiation exposure received by workers, The basic whole body external dose limit is 1.25 rems per calendar quarter (S20.101(a)).
However, an individual may be exposed to up to 3 rems per calendar quarter, proviaed that the accumulated occupational dose does not exceed a formula, 5(N-18) rems, where N is the individual's age at his last birthday (S20.101(b)).
In' order for a licensee to control the dose.to a worker within these limits, the licensee needs to know the magnitude of the dose received by.the worker in prior employments, so that additional' exposure in the licensee's facility will not cause the worker's tota 1' occupational dose to exceed the limits.
Major revisions to 10 CFR Part 20 that are currently underway change the whole body dose limit to 5 rems, annually, and delete the use of the 5(N-18) formula.
Therefore,. licensees will need to determine prior doses received during the current year in order to control his dose to the 5 rem limit.
Also, a requirement to advise each worker of his cumulative (lifetime) occupational dose has been added so that the licensee will still need to determine each workers prior dose.
2.
Agency Use for Information The NRC regulations do not require licensees to send NRC Form 4 to the NRC.
These records of exposure history are to be completed and maintained by NRC licensees so that they can be reviewed by NPC inspectors to determine compliance'with the dose-limit sections of the regulations.
_A
J 3.
Reduction of Burden Through Information Technology Many NRC licensees have computer systems in which the radiation exposure information required to be collected can be stored, and the information can be printed in any desired format.
NRC encourages the use of any applicable information technology.
4.
Effort to Identify Duplication The Information Requirements Control Automated System (IRCAS) was searched to identify duplication.
None was found.
5.
Effor t to Use Similar Information NRC Form 4 is the only source of information which summarizes the worker's exposure from prior employments.
There is no similar information which can be readily used to satisfy the needs stated in item #1.
6.
Effort to Reduce Small Business Burden The information required by NRC Form 4 is needed for the employees of small business as well as for the employees of larger business firms.
It is not possible to reduce the burden on small business and still meet the objectives stated in A.1.
7.
Consequences of Less Frequent Collection Less frequent collection would mean not checking doses received from previous employment. Workers could receive occupational doses in excess of the limits in 10 CFR Part 20 if the doses from prior employments are not considered in assessing how much exposure a worker can receive in his current employment.
This would also be true under the revised 10 CFR Part 20.
8.
Circumstances Which Justify Variation from OMB Guidelines None.
9.
Consultations Outside the NRC The NRC Form 4 to be required by the proposed 10 CFR Part 20 is being revised L
to accommodate the changes to Part 20.
It is being reviewed by many I
individuals (licenses, unions, dosimeter processors, etc.) during its development.
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- 10.
ConfidentialityLof Information The NRC'provides no pledge of confidentiality for this collection of 1information. The NRC neither receives nor maintains'the information collected on NRC-Form'4.
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'11.
Justification for Se'nsitive Questions The current NRC Form 4 contains no sensitive" questions, nor will the Form-4 developed forlthe revised Part 20.
- 12.. Estimated Annualized Cost to the Federal Government NRC cost is incarred by the inspectors reviewing the information on NRC Form 4, or its equivalent; and records maintained by licensees.
An average of 1.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> of inspection time per year is spent reviewing such records of each of about.100 reactor sites.
An average of 0.25 hour2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> of inspection time per 3 years is spent; reviewing such records of about 7,475 materials. licensees.
Therefore, the total inspection cost would be about $46,380/ year (100.x 1.5 hrs /yr + 7,475 x 0.25 hour2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> every 3 years = 773 hrs /yr x $60/hr).
Federal printing costs.for the forms would be about $2,000/yr. The total cost to the
' Federal government would be about $48,380/yr.
It is estimated that the cost to the Federal government for the inspectors reviewing the information on the NRC form 4 developed for the revised Part 20, would be about the same as for the current Form 4.
13.
Estimate of Burden
~
~ NRC Form 4, or its equivalent, must be completed by all 7,575 licensees.
Approximately 400,000 individuals are monitored and, by allowing a'10% annual turnover in the workforce, t.here would be 40,000 NRC Form 4s, or equivalents, required per year.
It is estimated that about 0.25 hour2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> of clerical time would be used to prepare the form, or its equivalent, using the. data obtained pursuant to S20.102, or about 10,000 hrs / year (40,000 forms x 0.25 hr/forn).
1.
-Number of recordkeepers.......................
7,575 2.
Annual hours per recordkeeper.................
~1.3 i
3.
. Total recordkeeping hours.....................
10,000 4.
Recordkeeping retention period................
Until the Commission authorizes their disposition 3
i It is estimated that the annual burden on licensees for the completion of the NRC Form 4 developed for the revised Part 20, would be about the same as that estimated for the current Form 4.
There would be a wide range in the number of forms completed and maintained by each licensee because of the tremendous variation in the size of NRC licensees.
The cost of this requirement is estimated to be about $200,000 (10,000 hrs x
$20/hr).
An additional 5%, or $10,000 is allowed for the cost of maintaining the records.
The total cost would be $210,000/yr.
Therefore, the estimated annual cost per respondent to respond to the collection is $28.
(The hourly rate is estimated at $20.00 because personnel that would be entering the data onto the Form 4 or into a computer system are paid at approximately this rate.
The costs of developing the data to be entered on the form are incle!ded in the costs of 10 CFR Part 20.)
The burden data and estimates are judgments of NRC staff based on experience gained as licensees and as regulators.
14.
Reasons for Change in Burden Burden is being increased from 7,500 to 10,000 hours0 days <br />0 hours <br />0 weeks <br />0 months <br /> annually.
The difference of 2,500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> is an adjustment based on NRC staff's projection that an additional 10,000 Form 4's will be completed by NRC licensees because they are monitoring more individuals in the growing nuclear power industry.
There is no increase in burden per submittal.
15.
Publication for Statistical Use Not applicable.
B.
COLLECTJ0g 0F INFORMATION EMPLOYING STATISTICAL METHODS Statistical methods are not used in the collection of information.
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D 1. tuttt AR af LLa &fcat (twtutsu. e45 ale;1CR. M 70%%. A;D 10 ?4 PAPt3w0tt RIMtIDk e
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U. S. NUCLEAR REGU(ATORY COMMIT $10N g,,,[N,,,,,
OCCUPATIONAL EXTERNAL RADIATION EXPOSURE HISTORY See instructions on the Back 4 IDENTIFICATION
- 1. NAME (PRINT - LAST, FIRST, AND MIDDLE)
- 2. SOCIAL SECURITY NO.
- 3. DATE OF BIRTH (MONTH, DAY, YE ARI
- 4. AGE IN FULL YEARS (N)
OCCUPATIONAL EXPOSURE - PREVIOUS HisTORV
'6. PREVIOUS EMPLOYMENTS INVOLVING6. DATES OF EMPLOYMENT
- 7. PE RIODS OF EXPOSURE 8, WHOLE BODY
- 9. RECORD OR CALCULATEO RADIATION EXPOSURE-LIST NAME AND (F ROM-T O)
(REM)
(INSERT ONE)
ADDRESS OF EMPLOYER
- 10. REMAR KS
- 11. ACCUMULATED OCCUPATIONAL DOSE
- TOTAL
- 13. CALCULATIONS-PE RMISSIBLE DOSE
- 12. CERTIFICATION:I CERTIFY THAT THE EXPOSURE HISTORY WHOLE BODY:
LISTED IN COLUMNS 5,6. AND 7 IS CORRECT AND COMPLETE (A)* PERMISSIBLE ACCUMULATED REM DOSE = 5(N-18)
(B) TOTAL EXPOSURh TO DATE REM EMPLOYEE'S SIGNATURE DATE (F ROM ITEM 11)
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(C) UNUSED PART OF HLM PERMISSIBLE ACCUMULATED DOSE (A-Si
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INSTRUCTIONS FOR PREPARATION - OF NRC FORM 4 This forrn or a clear and legible record containing all the of the individual as calculated under Section :
inforrration required on this form must be prepared by each 20.102. Dose is to be given in rem.
~ bcensee of the Nuclear Regulatory Commission who. pursuant to Section 20101, proposes to expose an Individual to a radiation
" Dose to the whole body" shall be deemed to in.
dose in excess of the arnounts specified in Paragraph 20.101(a) clude any dose to the whoie body, gonads, active of the regulations in Part 20, " Standards for Protection Against blood forming organs, head and trur*, or lens of Radiation," 10 CFR; The requirement for completion of this
. eye.
form is contained in Section 20.102 of that regulation. The information contained in this form is used for estimating the '
' ltem 9. After each entry in item 8 indicate in item 9 extemal accumulated occupational dose of the -individual for whether dose is obtained from records or calcu-
~ whom the form is completed. A separate NPC Form,4 shall be lated in accordance with Section 20.102. -
completed for each individual to be exposed to e radiation dose itern.10. Self emptanatory.
in excess of the limits specified in Paragraph 20.101(a) of Part 20 of the Commission's, regulations.' Listed below by item are Total Accumulated Ocetipational Dose (Whole Body) instructions and additional information direcaty pertinent to com-pleting this form; Item 11. The total for the whole body is obtained by sum-mation of all values in item 8.
Identification Certification
!em 1. Self explanatory.
Item 2. Self emptanatory except that, if individual has no social ecurity number, the word "none" shall be item 12. Upon completion of the report. the employee must certify that the information in Columns 5,6, and 7 inserted.
is accurate and complete to the best of his know-ltem 3. Self explanatory, ltem 4. Enter the age in full years. This is called "N" when iedge. The date is the date of his signature.
used in catcelating the Perrnissible Dose. 4 is equat to the number of years of age of the individual on his last birthday.
Calcufstions Item 13. The lifetime accumulated occupational dose for Occupational Exposure each individual and the' permissible dose under Paragraph 20.101(b) are obtained by carrying out item 5. List the name and address of each previous em-the following steps: The value for N should be taken from item 4. Subtract 18 from N and multi-ployer and the address of employment. Start with the most recent employer and work back.
ply the difference by 5 rem. (For example, John -
Smith, age 32; N = 32, PAD = 5(3218) = 10 rom.)
l Enter totaf exposure to date from item f f. Sut>
include only those periods of* employment since the eighteenth birthday involving occupational
, tract (b) from (a) and enter the differente under
' (c). The value in (c) represents the unused part of '
exposure to radiation. For periods of selt-employ.
the permissible accumulated done. This value for ment, insert the word "self-employed."
permissible dose is to be carried forward to NRC item 6. Give the dates of each employmerit listed in item 5.
Fomy5, " Current Occupational External Radiation ltem 7. List periods during which occupational exposure Exposure (Whole BodyL" to radiation occurred.
item B. List the dose recorded for each period of exposure from the records of previous occupational exposure item 14. Self explanatory.
- m emm reeuw ce s.enewee of the empiova soacwaed.
PNVACY ACT ST TEMENT l
Pursoant to F U.S.C. 662afe) (3), enacted into law try section 3 of the Privacy Act of 19N (Public Law 93 579). the folic-wing staternent is 1'
who supply information to the Nudear Repletary Commission on NRC Form 4. This informationis maintained in a eystem of reco
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des + bed at Federal Register 45344 (October 1,1975L Sections 53. 63. 65. 61,103,104,161(bl. and 161(o) of the Atomic Energy Act of 19tW. es amended (42 0.S C. 2073. 2003. 2006
- 1. AUTHORITY 2133,2134,2201(b), and 2201lolt The authority for soliciting the social acurity number is 10 CF A Part 20.
The information is used by the NRC in its evaluation of the risk of radiation exponere associated with the licensed setivity and
- 2. PRINCIPAL PURPOSEIS) in amorcising its statutary responsibility to monitor and reguinte the safety and health practicas of its licensest The data permits e current and longterm exposure expor4nce among types of licensees and among licensses within each typs. Date on your espomare to r upon rewest.
The intor motion may be used to prov'.de deto to other Federal and State agencies Irwofwed in monitoring sid/or evaluating radiation on-
- 3. ROUTINE USES pceure received by individuals emptored as radiation woriters Jn a permanent or temporary basis and exposure received by m mey also be dia:losed to en appropriate F ederal. State, or loral agency in the event the information indicates e violation or potent coarse of an administrothe or jud6cist proceedin9-81is voture
- 4. WHETHER DISCLOSURf't$ MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUA4 OF NOT PRO 1ery that you fumish the requested Information, including social sooJrity numbr;however, the licerasse must have a s nmples whom the licerees proposes to expose so e redistien dose in amcess of sne amounts specified in 10 CF R 20.101(a). Fmaure to obtain bebre permitting m;ch owposure may a4bject the licenses to enf vosment setion in ac
- 5. SYSTEM MANAGER (S) AND ADDRESS Director, Office of' Nuclear Regulatory Rewatch U.S. Nuclear Regulatory Comminion, Washmgton, D.C. 20555 eee ses-ass I
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i INSTRUCTIONS FOR PREPARATION OF NRC FORM 4 l
This form or a clear and legible record containing all the of the individual 'as calculated under Section inforrration teovired on this form rnust be prepared by each 20.102. Dose is to be given in rem.
licensee of the Nuclear Regulatory Commission who, pursuant to Section 20101, proposes to expose an individual to a radiation
" Dose to the who e body" shall be deemed to in-done in excess of the amounts specified in Paragraph 20.101(a) clude any done to the whole body, gonads, active of the regulations in Part 20, " Standards for Protection Against blood forming organs, head and trunk, or lens of Rad.ation," 10 CFR. The requirement for cornoletion of this
- eye, form is contained in Section 20.102 of that regulation. The information contained in this form is used for estimating the item 9. After each entry in item 8 indicate in hem 9 extemat accumulated occupational done of the individual for whether done is obtained frcm records or calcu-whom the form is completed. A separate NRC Form,4 shall be lated in accordance with Section 20.102.
completed for each individual to be exposed to a radiation done item,10. Self-explanatory, in excess of the limits specified in Paragraph 20.101(a) of Part 20 of the Commission'sTeguistfo~ns ~* ]directly pertinent to com-isted below by item are Total Accumulated Occupational Dose (Whole Body) instructions and additional information pletmg this form:
ltem 11. The total for the whole body is obtained by sum-motion of all values in. Item 8.
Ideritification Certification item 1, Self explanatory, item 2. Self explanatory esceot that,if individual has no social security number, the word "none" shall be item 12. Upon completion of the report, the employee Must certify that the information in Columns 5,6, and 7 inserted.
is accurate and complete to the best of his know.
f tem 3. Self explanatory, Item 4. E nter the age in full years. This is called "N" when ledge. The date is the date of his signature.
used in calculating the Permissible Dose. N is equal to the number of years of age of the individual
~
Calculations on his last birthday.
item 13. The lifetime accumulated occupational done for Occupersonal E xposure each individual and the permissible dose under Paragraph 20.101(b) are obtained by carryi.g out the following steps: The value for N should be ttem 5. List the name and address of each previous em-taken from item 4. Subtract 18 from N and multi-ployer and the address of employment. Start with ply the difference by S rem. (For example, John the most recent employer and wo* back.
Smith, age 32; N = 32, PAD = 5(3218) = 70 rem.)
Enter total exposure to date from item 11. Sute Include only those periods of' employment since the eighteenth birthday involving occupational tract (b) frcm (a) and enter the difference under (c). The value in (c) represets the unused part of exposure to radiation. For periods of self emptcy.
the permissible accumulated dose. This value for ment, insert the word *'self-employed."
permissible done is to be carried forward to NRC tiem 6. Give the dates of each employment listed in item 5.
Fem 16, " Current Occupational External Radiation ltem 7. List periods during which occupational exposure Exposure (Whole Body)."
to radiation occurred.
item 8. List the dose recorded for eoch period of exposure from the records of previous occupational exposure item 14. Seifexplanstory.
4
%s enem reewes she aseneture er the empneves -
PRIVACY ACT ST TEMENT Pure ant to 6 U.S.C. 562 ale) 0), enacted into law by esetion 3 of the Privacy Act of 1974 (Public Law 93 670), the following statement is f who supply informat,on to the Nuctaar Respletary Commision on NRC Form 4. This informeWonis maintained in a system of records described at Federal Register 45344 (October 1,1875).
Sections 53,63.66, B1,103,104,161M, and 161lol of the Atomic Enoryr Act of 154, as amended 142 US.C. 3073,2003,3086,2111,
- 1. AUTHOMTV 2133,2134,2201M, and 2201(o)). The authority for soliciting the social security number is 10 CF R Port 30.
The informatim is used by the NRC in Ds evaluation of the risk of redetion expoeste assotimed with the lloansed medvity and
- 2. PRINCIPAL PURPOSE 15) in exercisine its statutory responsibility to monitor and rop,tste the selety and heelth practices of its licenssek The dets permis a me current and innetarm exposure aponence among types of licensees and among licensees within auch type. Dom en your esponsre to re upon respeet.
The information may be veed to provide det to othw Federti and State spensies inwelved in monitwing md/or evaiusting reestion m-3 ROUTINE USES paaste receeved by individuals employed as redation sworkara on a permonant or temporwy besla and==fme received b may also be dientemed to en sopropriew Federal, State, or local agency in the event the information indiostas a violation or po esseres of an admirustredwe or judcist proosodin0-
- 4. WHETHE R DISCLOSURE tS MANDATORY OR YOLUNTARY AND EF FE CT DN INDIVIDUAt OF NO It h vetun-tory that you fumish the recuened inf armation, including social security number;howaww, the limneme must here a sempiend f
emom the hasnese propossa to expose a) a radation dose in mamme of tne amoung spoolfied in 10 CFR 20.1014al. Fellure to stimin t tortore ps. mitting nach suposure mey met lect me hasness to enforcement action in accordance wtth 10 CF R 30A01. The sosist a me: NRC has an accurate identifier not subject to the aulncidence of smilar nemos or birthosaw among the large number of pers
- 6. SYSTEM MANAGER (S) AND ADDRESS Director Office of' Nuclear Regul6 tory Rosserch U.S. Nuclear Ragulatory Commissen, Washenaton, D.C. 20666 eve somes
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