ML20247R010
| ML20247R010 | |
| Person / Time | |
|---|---|
| Issue date: | 05/26/1989 |
| From: | Amenta J NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| To: | |
| References | |
| OMB-3150-0006, OMB-3150-6, NUDOCS 8906070111 | |
| Download: ML20247R010 (9) | |
Text
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l Request ior' OMB Revievf" ' " ", U"' g/
5'*""' '2""4 3 y
n wn m Important u., u
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~ Read mstructions before completing frm Do not'ust the same SF 83 Send three cepies of this form, the material to be rev'ewed. and for to request boti en ExecuSe Orcer 12291 review and approval under paperwork-three copies of the support.;g.,tatsci.U.;, O,.
the Paperwork Reduction Act
' Answer all qacstions in Part L 11 this request is for review under E.O.
Office of information and Regu'atory Affairs
~ 12291. comp'cte Part li and sgn ihe regulatory certification. If this Office of Management and Budget recuest is for approval under the Paperwork Reduction Act and 5 CFR Atte ntion: Docket Library. Room 3201 1320. tip Pa*t II. comsete Pert fl! and stn the paperwork certification.
Wash;ngton, DC 20503 PART 1.-Complete This Part for All Requests.
' 1. Depetment,gency and eu easic't.ce cronstmg request
' 2. egency code
~
r U.S. Nuclear Regulatory Commission l3 1 5 0
- 3. Name of pc' son wt a can test ansv.et cuest.ons rega%ng t.h:s request Telepnone number B. G. Brooks
( 301 ) 492-3738 Cdie of informaDon col:ection er ru1marng NRC Form 5, Current Occupational External Radiation Exposure
- b. Lei;a ntrcr4 f or w.fw"6 tion co ection or 'u e (cae Unned States Code. Pucht Law, or becut$e Orcer) v
_ 42 use 2201(o)
, or
- 6. M'erteo p bbc (cf.ecx all that an,-)
s O rederaiagencies or employees 1 C revid.ais er hcaseholds 3 0 rarr,,
6 O Non profitinstitutions 2 C St.Pe iv torM powernments 4 ( Businesses or ouer for-profit 7 C Small businesses or organizations PART ll.-Complete This Part Only if the Request is for OMB Review Under Executive Order 12291
- 7. Regu aSon IcentAer tvu'nt,er (RIN)
_ ~~ _ _
.._ _, or, None assigned C C.Tyve of suonsse <cnto one or each ca'cyc'y)
Type of review regaested
' C: ossification Stage of dewelopmen 1 C standard 1 C Mer 1
Proposed or draft 2
Pending 2 C f.orma,or 2 U Finaloranterim fina!.withpnor p opotrt 3 C Emergency 3 U rinal or intenm final without yior proposa!
4 Statutory or ludicia! deadhne
- 9. CF R section atte:ter JR
- 10. Dxs ths +reatur mwn repert'nc c 'ecorSe-pq reauvements that require CMB approva! under the Paperwork Reductioq Art and 5 Cf R 1320?
Yes O No I O Yes 2 C No
- 11. If a r ajor ru+ is there a 'egsiawy. wan tneysis aticed' 3 0 ves 4 0 No 11 'No," d.c OME wuae t"e anays)
Certification for Regulatory Submissions in sutwtung Ws request f or Ct/B reMw.the aJthor. zed regulatory contact and the program official certify that the requirements of E O.12291 anc any apphcable poisCy directWes P3.0 Deer Comphted with 5 gneture oIRe. ettcas Date l
EgnaturioE6;ec regulatory cortact Date
- 12. (OMB uu cnty)
Standard Form 63 (Rev 9 83)
Preom.s ec ta a cMve 83 108 Presc@d by OMB Nsty?$.0 7 (y.4034 S CFR 1320 and LO 12291 8906070111 890526 PDR ORG EUSOMB PDC
PART tlL-Complete This Part Only if the Requestis for Approvalof a Collection of Inictmat:on Under the Paperwork Reduction Act and 5 CFR 1320.
l a. re m ~.sc -se reeds. aes 3,e attectee n.b:ic in so words e iess " Nuclear Radiation Monitoring, Radiation Exposure" NRC Form 5 is used to record the current occupational exposures of individuals to ensure that the regulatory limits are not exceeded.
44 T pe rr rrt 6cr tCec* cs (checs ol'y ore) y in forma Son collections rof contt!* red in rules
- ]i'*gvvsAminen 2 C Emergency submmsson(cerfdicafron attached)
Informatkn c' lect!vns ccntainedin rules A
3 j Ersvg r>gAw pc charge proposec)
E final or iritenre final vathout pr.or NPRM
- 7. Enter date of expected or actoM f ederal 4 C Ncte.e c' vt:.r:M semau g f,NDPM)
A C Peptar submission Reg. ster pubhcaten at ths stage of rulemahng 5 C Ftr.ai G / wH reco.s ; pL biisrec B C Emerge,cy suemmuon(cet6 cation x ached) pnoath, day. f ear) iS i>pe r.e. en tv !eC (c1ca cm.r e"e)
] Ma tonee v 4
Reiratatement of a previously approved colleet'on f or whicn oprevat m 3 cu~~< s, a;cro.ed cobection 4
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- N.'at ca ta*0 of a cuqently approved collection 5 C Eosteng collacbon in use weout an oM9 control nur3ber 3-j a ;* : t*
- s.Strce rr in the rnethod of co';ectio7
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. ?g " t /t ~. u w
sue sta,ca Cicptio-'al form number (sD
- 22. Purpose of mf ormat on conection (check as mary as aph) 1 C Apphcation for benehts NRC Form 5 2 r ' Propam evalut'on 4i c rer t g or ? i :? ce 5. de.
3 Gm.: purpose s stist.cs 4 L Rspatory or comprance 1,
a'
-mm oe is 5 C Fmg am plancarE y management 5
ce*" en tet r er c ' e,t d wwus (L e i wu C;ue::
6 C Researcn 7 [ AJdit L.i Oe
'n*6 p- ' g n ); ~e: u J)
- 23. f reovency of recordreepeg or reparung gheca aa f utappry)
) emt enwomg teca-11 Recordheepirg i Wr ter c' '*cercra:*:s L
2 Reporting y?.n, e w c '.v sr.
j i c:t ea n etca g :, a ; ce j t,TeJ R-e M 2 C On occas.on 4 N ower {ey cgg l lMime yea's 3 { g,,yy 1: '#
- .a! b" dc q 4
MontNy
__166*320 5
Quarter!y 1 %"'eJ *e i15 m 19)
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2*:,cr t Of,T m m e 4m, D 7y e nyany t'n.cer e l rs e,:
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9 C otne < describe) w *ci Y ;rr ge 41T580 3
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2 0.. " '? < '- " r P ar t! O!M 'O W c't. rr ter or c:r "um ber 24 Pef porgerts' obhgat en ta compty lct ccr the strongest othgcon rnat appl,es) 3150-0006
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gg9 i % w.e ra, so 4/30/92 l
3 xj Mvicatyn
, e?.: rater.a1 a fn;'et or irstitut<ons or is tr e pomary pesose of the collection rela *ec to federa' educ aSon progran s? O Yes )C No A -
ns :,'
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g: 'ese:* mspr dents or daes tne agency recomrnend ur prescr be the use of sar* phrg or stchstical r el us C Yes Lj No y
X 26 NH "
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> 3 mr. :er-T i ! d e.' 3tery a dhy :, 'o* re m' ort ation covection 1.0 m _Part.20
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% e n.n % i1. x on v c '- 7 9 sop o.a:. tne agency teal the semor o'ficial or an autnonrec representative. ce Aes that tre recurerne :s at 5 CF R 1120. tt e
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- s o' ci ectives. and any otner apphcab;e mformation poir) Cirectwcs have been compted mth
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- PARTill. r-Comp!ste This Part Onlyif the R
- quist is for Apprrvtlcf a Cellecticn
- of Inf ormaHen Under the Pap:rw*rk Reducti:n Act end 5 CFR 1320.
- 13. bstract-
- esenb reees..ses a,d aftecteo puse in So woros or iess "Nuciear Radiation Monitoring, Radiatton Exposure" NRC Form 5 is used to record the current occupational exposures of individt.als to ensure that the regulatory limits are not exceeded.
- J. h;* or Mforf"aton colection (
- 3ect only one) letterma tion collections tot contained in rules 12 ? ego.ar sam'ss on 2 C Emergency submission (cerfihCation attached)
Informatica c:,11ections contained in rules
- 3 5 Ewg regulation (no charTeproposed) 6 Fmal or intenre fina' withou* pr or NDRM
- 7. Er.ter cate of expected or actual Feferal t.C Notice of yccesec r aemabrg(NPRM)
A Regular subm.ssion Register pubhcation at ths stage of rulernawg L 0 Ier.aL as?M eas renous 1ps%sr'ed B D Emergency sut.'nsssion (cencet on atta:ned)
(mcatt'. Jay. yearl
! $. T)pe c: rev ew requested (cf eca only cae) 1.._i Ne a -ohectror 4 L.J Reinstatement of a crenously approved coCertion for whicr. appr: val as M M 2 C Ceu 9a 7f a cueer tiy sorrove'J collection
.i / p;e 5,ori c,f.r e notat oa ca'e of a currently approved collection 5 ] Eutmg collect.on.n use w tnout an CM9 controt number
- : art a-v r y se - "a s 3 stance or in the method of conection
- 'iew s. irt :n % ~ ter v f '.sA ce stancardl:ptionalform number (s))
- 22. Purpose ' mforrnat on codectron (**rck as "ary s 1901 1 9
1 [ Acchcat oo 'or beretts NRC Form 5 2 r: P'ograf, evalwat,on 3 'k; Ge e alpurpose statist,cs l
a W.e 'eMrt'*g or tsecs/e b/ den I
s_
Regiatory or compi acce
,, te r moor.:e*ts I
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- ' res;: ses cs'i*4:ence,t 5 C F oram ctanr.rg or rrar.agerrent
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re w s;e e w m ezer i
J icta' reen eeomg r us (se 1 tares 1,rse 2) 166,320 2 O onuccas,on l
oece,wp. g et v te,es Lifetime rea s 3
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- u..r L.,3n.-cen win,y 106*320 e
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uarteoy
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124,740 6 2 sem.n~ a"y
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+ 41e580
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by snatier etch
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- 24. 3erace:etts' obt gat or toco my s:*c me st orYnt echpt'on tt aturt es) 3150-0006
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- 5: *19
- q rD' % UW.e h y,,7ggto obta n ereg*gia a tener,t 4/30/92 l
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- C 'lt Ns ' *e * 'r educational agencies or it'stitutions or is the primary partose of tre relie@ cyrry 5
- T eceT ecc 3* r" TOTJ's' 2 Yes [ No N );f s P $ !+e' y ust s t *C 'g *.0 leieft espondents or dOes the ageqcy re;omr*eqd er p'esce se the use of sa"' h"f or stM st:ca: y 6,s:s Yes _g] f4u
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%* :2. & :=':s or crectives, ar'd any other apphcable inforraation pobr y -ectws' ave been come ao..e l
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t-.
OMB SUPPORTING STATEMENT FOR:
t CURRENT OCCUPATIONAL EXTERNAL RADIATION EXPOSURE Description of-the Information Co',lection'-
NRC Form 5 is used as a current record of occupational radiation doses for:each individual:for whom personnel monitoring is required by 10 CFR Part 20.
Section 20.401' requires each licensee to maintain records showing the radiation exposure of all individuals for whom personnel monitoring is required by 920.202.
The records are to be kept on NRC Form 5,.in accordance with the instructions contained in that form or on clear.and' legible records containing all of the irformatinn required by the NRC Form.
The requirements for provision-of personnel monitoring equipment are set out in $20.202 in terms of percentages -
of the dose-limits which the individual is likely to receive.
A.
JUSTIFICATION-1.
Need for the Collection of Information It is. essential that licensees maintain records-of the occupational doses of their employees.in order to establish-whether these doses have exceeded the
. limits.. Dose-records are important also for assessment and control of ongoing programs, particularly with respect to. maintaining occupational exposures as
' low as_is reasonably achievable (ALARA) and identifying unfavorable trends.
In addition,'it is in the interest of the worker that the licensee keep accurate
-dose records.
The licensee is required to report certain exposure information
.to a worker,'and to the NRC, and a worker may request other reports of occupational exposure that flow directly from the NRC Form 5 records.
This would also be true under the soon to be published revised 10 CFR Part 20.
2.
~ Agency Use of Information The current NRC regulations do not require licensees to send form 5 to the NRC.
These records are to be completed and maintained by NRC licensees so that they can be reviewed by NRC inspectors during periodic inspections to determine compliance with the dose-limting sections of the regulations.
The revisions to 10 CFR Part 20 do require licensees to send copies of Form 5 to the NRC or to submit the same data electronically. The NRC would use the information to develop data similar to that previously obtained from annual statistical reports and individual termination reports, which will no longer be required to be submitted to the NRC.
The NRC uses of such data include the following:
l^
= - - _ _ _ _ - _ _ _ _ _ - _ _ _ _
(1)-- Examination of trends in radiological protection parameters, such as'.
- collective and average doses,the number of workers monitored, etc, assists the.NRC in?its evaluation of-the effectiveness of the licensee's overall 4
radiation protection and ALARA ef forts.
(2) Allows comparative analyses of radiation protection performance of various types of licensees, of licensees within one type, of US and. foreign facilities, etc, to be performed.
(3)~ Assists the.NRC in its evaluation of occupational risks as compared to s..
risks'to the public.
- 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.
This allows them to quickly print the information in any desired format or to transmit it via
~
electronic media.
NRC encourages the use of any technology which will reduce burden.
L 4.
Effort to Identify Duplication
.The'Information Requirements Control Automated System (IRCAS) was searched to identify. dup *,1 cation.
None was found.
5.
Effort to Use Similar Information NRC Form 5 is the only available source of information which contains-the current record of occupational radiation doses for each individual for whom personnel' monitoring is required by 10 CFR Part 20. 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 5 is needed for all monitored individuals regardless of the size of the business by which they are employed.
It is not possible to reduce the burden on small businesses and still meet the objectives stated in A.I.
7.
Consequences of Less Frequent Collection The radiation dose limits, specified in 620.101, are in terms of rems per calendar quarter.
Because of the quarterly limits, the data recorded on NRC Form 5 are required to be for periods of time not exceeding one calendar quarter.
If the data were collected less frequently, identification of those workers who had exceeded the quarterly occupational radiation protection limits would be delayed.
Quarterly entries are required by the regulation.
i l
I 2
n The revised 10 CFR Part 20 contains annual limits rather than quarterly limits.
Therefore, for similar reasons, the data recorded on Form 5 would be required for periods of time not to exceed one year.
8.
Circumstances Which Justify Variation from OM3 Guidelines None.
9.
Consultations Outside the NRC The NRC Form 5 to be required by the revised 10 CFR Part 20 is being revised to accommodate the changes to Part 20.
The form is being reviewed by many individuals (licensees, unions, dosimeter processors, etc.) during its development.
10.
Confidentiality of Information The NRC provides no pledge of confidentiality for this collection of information.
Currently, the NRC neither receives nor maintains the information-collected on NRC Form 5.
The revised Part 20, however, requires the submittal of the information provided on Form 5 to the NRC.
The NRC pledges to protect the confidentiality of the information by placing it in a system of records that is subject.to the requirements of the Privacy Act.
11.
Justification for Sensitive Questions The current NRC Form 5 contains no sensitive questions, nor will the_ Form 5 developed for the revised Part 20.
12.
Estimated Annualized Cost to the Federal Government NRC cost is incurred by the inspectors reviewing the information on NRC Form 5, or equivalent record, maintained by licensees.
An average of 2.5 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 the information on NRC Form 5, or equivalent record, at each of about 100 reactor sites.
An average of 0.5 hour5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> of inspection time per 3 years is spent reviewing such records of about 7,475 materials licensees.
Therefore, the total inspection time would be about 1,496 hrs /yr (100 licensees x 2.5 hrs /yr + 7,475 licensees x 0.5 hr/3 yrs), with an associated cost of about $89,760/yr (1,496 hrs /yr x $60/hr).
It is estimated that the cost to the Federal government for the inspectors reviewing the Form 5 developed for the revised Part 20 would be about the same as for the current Form 5.
3
m 13.
Estimate of Burden NRC Form 5, or its equivalent, must be completed by all licensees for all individuals requiring provisions of individual monitoring devices or services.
i It is estimated that 7,500 NRC licensees monitor about 400,000 individuals per year, that entries are made on NRC Form 5, or equivalent record, monthly (or whenever they receive the results from dosimetry processors), and that each entry requires about 2 minutes (0.033 hour3.819444e-4 days <br />0.00917 hours <br />5.456349e-5 weeks <br />1.25565e-5 months <br />) for a total of about 158,400 hrs /yr (400,000 individuals x 0.033 x 12 entries / year).
An additional 5% or 7,920 hours0.0106 days <br />0.256 hours <br />0.00152 weeks <br />3.5006e-4 months <br />, is estimated for maintaining each required form or record for a total of 166,320 hours0.0037 days <br />0.0889 hours <br />5.291005e-4 weeks <br />1.2176e-4 months <br /> / year.
1.
Number of recordkeepers.......................
7,575 2,
Annual hours per recordkeeper................
~22.2 3.
Total recordkeeping hours.....................
166,320 4.
Recordxceping retention period................
Until the Commission authorizes their disposition It is estimated that the annual burden on licensees for the completion of the NRC Form 5 developed for the revised Part 20 would be about the same as that estimated for the currer.i Form 5.
There would be a wide range in the number of forms completed and maintainet by each licensee because of the tremendous variation in the size of NRC licensees.
The cost of this requirement is estimated to be about $3,326,400 (166,320 hrs x
$20/hr). An additional 5%, or $166,320, is allowed for the cost of maintaining the records.
The total cost would be $3,492,720/yr.
Therefore, the estimated annual cost per respondent to respond to the collection is $461.
The burden data and estimates are judgements of NRC staff based on experience gained as licensees and as regulators.
(The hourly rate is estimated at $20,00 because persennel that would be entering the data onto the Form 5 or into a computer system are paid at approximately this rate.
The costs of developing the data to be entered on the Form 5 are included in the costs of 10 CFR Part 20.)
4
i l-14.
Reasons-for Change in Burden Burden is being increased from 124,740 to 166,320 hours0.0037 days <br />0.0889 hours <br />5.291005e-4 weeks <br />1.2176e-4 months <br /> annually.
The difference of 41,580 total recordkeeping hours is an adjustment based on the'NRC's. estimate that an additional 100,000 persons will be monitored for exposure to radiation.
This is due primarily to the increasing number of persons being monitored by the growing nucisar power industry.
15.
Publication for Statistical Use Not applicable.
B.
COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS Statistical methods are not used in the collection of information.
5
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90aWO CCPI4sil15 tif,AADl'IG CACMt fl11Mrt 101:2 Cit 0aD$ AND SIPotf5 MnEDi31 SAANCM (P-$2),
U.S. aKLtK2 RIGUL4JDif CO*llilGR. hASMIE10N DC 2055$ Ano 10 ist f artams atautilos enonti ono-e:%), oract or MaAarntn ano suutti, utsalnica, oc roSot.
NRC Form $
tte ett U M Approved by OM8 315 0 40 n6 80 CF R 20 U. S. NUCLE AR REGULATORY COMMISSION.
g y,yg; CURRENT OCCUPATIONAL EXTERNAL RADIATION EXPOSURE i3 See instructions on Back 1
IDE NT IF IC ATION a
- 1. iJAME (PRINT - Last, hrst, and middiel 2 SOCI AL SECURITY NO.
- 3. DATE OF BIFt 'H (Month, day, yearl
- . N AME OF LICENSEE 5 DOSE RECORDE D FOR (Ssweify, Whole body;
- 6. WHOLE BODY DOSE
- 7. METHOD OF MONITORING (e.g, Fiim Badge -
skin of whole body; or hands arni lorearms.
STATUS trem)
F B, Pocket Chamber - PC; Calculations - Calc )
feet and ankles.):
X OR GAMMA -
BETA-NEUTRONS.
CALENDAR OUARTER
- 9. X OR GAMMA
- 10. BE T A 11 NEUTRON
Lif E TIME ACCUMLf L A IE D DOSE 14 FRiveOUs TOTAL beel il TOIAL ouARf 6 RLY la IUT AL ACCUMUL Af tO 17 t'f r'M ACC DO5( 61N tRi eramt 18 UNUKf D PART oF Pf RMissteLE DOtt Dost beme ACCUMULAIE D DOSE deemi
..e
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[._
ll l INSTRUCTIONS FOR PREPARATION OF NRC FORM S -
l,'
Thi preparation and safeleeeping of this form or a clear and legib;e tiems 9, - Self explanatory. The values are to f)e iven in rom. -
o eocord containing all the mf ormation iequired on tfus form is re-10 and All measurements are to be interpreted n the twst ouired pursaant to Section 20.401 of " Standards for Prptection 11.
method known and in accordance with Parageaph 20.4(c).
' Aga,nst Radiation," 10 CF R 20, as a current record of occupational Where calculations are made to determine dose, a copy of eurSnal radiation exposures. Such a record must be maintained such calculations is to be mamtained in conjunction with J.
4 j.
for each individual for whom personnel mordtoring is required this record. In any case where the dose for a calender under Saction 20.202. Note that a separate NRC Form $ is to t:e nuarter is less than 10% of the value pecified m Paragraph -
20.101(al the phrase "less than 10% may be entered in -
used for recording en ternal exposure to (1) the whole body; heu of a n,umerical value.
(2) skin of whole body * (1) hands and for serms; or (4) feet arti
. Enkles, as provided by item $ below, item 12.
Add the values under items fr 10 and 11 for each period LsstId below by item are instructions and additional mformation of exposure an.d record the total. In calculating the 4tuectly pertinent to completing this form.
" Total" any entry less than 10"." may be disregarded.
Item 13.
The running totas is to be maentaened on the basis of
' Id'"IC8UO" calendar quarters. Paragraph 20.3(al (4) defines calendar ilum 1. Self explanatory.
quarter. No entry need be made an this item of only l'
l Item 2, Self explanatory except that, af individual has no social calendar quarter radiation doses are recorded in items 9, security number, the word "none" shall be enserted.
10,11 and 12.
f "y
Lifetime Accumulated Dose (Whole Body)
NDT E
- If the ticensee chooses to keep the endividual's -
Occ"pitional E xposure exposu.e below that permatted in Paragraph 20,101(a), items
. Item 5, " Dose to the wr Ae body" shall be deemed to mclude any 14 through 18 need not be completed. However. in that case -
. dose to the whole body, gonads, active blood forming the total wliole body dose for each calendar quarter recntded
' organs, head and trunk, or lens of eye. Unles the lenses in item 13 (or item 12 if quarterly doses are entered in item of the eyes are protected with eye snields, dose recorded
- 12) should not exceed 11/4 rem.
as whole body dose should include the dose dehvered If an Individual a.s exposed uruler the provisions of Paragraph 20.101 through a tissue equivalent absorber having a thickness of (b), complete Items 14 through 18 at the end of each calendar l
300 mg/crn2 or less. When the lenses of the eyes are prc>
quarter and when the 1heet is filled. Values m item 13, when m the of at least 70be shieldt having a tissue equivalent thsch ness m'ddle of a calendar quarter, aryd values in liero 18, must be brought tected with e ic mg/cm2, done recorded as whole body dose forward to nemt sheet f or each sndividual.
l should include the dose delivered throug/cm,{ issue equivalent ha Item 14.
Enter the previous total accumulated dose from previous absorber having a thsekness of 1,000 mg or less.
t dose records for the individual (e g from item 16 of NRC
- Dose recorded as dose to the skin of the whole body hands Form 5 or llem t 1 of NRC Form Al The totaloccupahonal and forearms, or feet and ank(es should include the done radiation dose received by the aridividual must be entered delivered through a titsue equivalent absor'ber havi in this 4 tem. including any occupational dose received
. thickness of 7 mg/cm7 or less. The dose to the sk,ng e m of from sources of radiation not hcensed by the Commisson the whole body, hands and f orearms,ur feet and ankles 11 the individual was exposed to sources of radiation not
' should be recorded on separatt forms unless the dose to heensed by the Commission during any calendar Quarter -
those parts of the body has been included as dose to the atter completing NGC Fum a and personnel monitorer.g whole body on a form maintained for recording whole body equipment was not worn by the individual. It should be
], at 'c as Item 6. - hs need be completed only when the sheet is used e
pa c
da Qua to record whole body exposures and the licensee is
' exposino the individual under the provisions of Paragraph Item 15.
Enter the total calendar quarter dose from item 13 (or 20.101(b) which allows up to 3 rems per quarter to the from item 12 at quarterly doses are entered in item 12) whole body. Enter in this item the unused part of per-and the date designating the end of the calendar cuarter missible accumulated dose taken from previous records of.
In which the dose was received (e.g., March 30,1962).
esposure i e. Item 18 of the preceding NRC F orm 5 or item '
Item 16.
Add item 14 ant' Item 15 and enter that sum.
13 of NRC Form 4 of the individual s esposure during item 17.
Obtain the Perm wble Accumulated Dose (PAD)in rem for the WHOLE BODY. "N" is equal to the number of '
employment with the hcensee Degins with this record years of age of the individual on his last birthday. Suty 4 ltem 7, Indicate the method used for monitoring the individual's tract 18 from N and multiply the dif terence by b rem esposure to each type of radiation to which he is exposed (e g., John Smith, age 32, N = 32, PAD = 5(32-18)
! in the course of his duties. Abbreviations frisy be used.
70 rem.)
llem 8. Doses received over a period of less than a calendar cuarter item 18.
Determ ne the unused par of the PAD by subtracting '
need not be separately entered on the form provided that item 16 from ltem 17. The unused part of the PAD the licensee maintems a current record of the doses received is that portion of the Lifetime Accumulated Dose for by the individual which have not as yet been entered on the the individual remaining at the end of the period form. The period of exposure should specify the day the covered by this sheet.
measurement of that exposure was initiated and the day on wh,ch it was terminated. For example of only quarterly the period of exposure for the first
' doses are entered, f 1962 might be taken as running from calendar quarter o and would be ind.1,1962, through Friday, March 30 1962,icated in this item es Jan.1,1962 Mar. 30, Monday, January 1962. If weekly doses are entered, a film badge issued Monday moming, January 1 1962, and picked up F riday January 6,1962, would be in,dicated as Jan.1,1962-Jan. b.
1962.
PRIVACY ACT STATEMENT
' PiIruet to 6 U.S C 552atel(3L *nact*d mia ta* by section 3 of lhe Pnvacy Act ut 19 74 (Pubhc Law 93 579L the tDilowing statement g lurnghed to mdivsouals who
' (
- '"80'F 'rdormaton to trie Nut.sese Repatory Commessen on NAC F or'n 5 1'ns m'or'rahon s maxamec e a sys'em o' recoros oes gwee as NAG 21 ano oesc abro at 40 Federal R*gister dr34410ctobei 1,19 75) a
~ 1. AUTHORITY S*chons 53,63. 65. 81. lP3. lD4.161 tb). and 161tol ot the Atomic E n*rgv Act of 1954.as enwnded l47 U S C 20 73. 2093.2095. 2111,2133 7134. ??D11bl, and 220lloR The authohl, for lohcetmg the social securst, number is 10 CF R Part 20.
? PRINCIPAL PURPOSEiSi The minimation a used bi tiw NRC m its evahistion of the risk of red.ation esposure aswc.ated with the acensed activity and m anerosmg ett statulotv responutuhti to momtor and segulate the sal *ty and health prattaas ul itshcenr**s The data preinits a meaningtui corriparison of both cut-rent and long term espusure espesence among tysws of hcenven erwt among hcens**1 ndhm each tvie Data on vom *inuup* to rad,at.on a swiat.le to vou upun i
vout request
~l 3 ROUTINE USES The mturmat.un may sw used to prov* data to otter F eoreal and State agencies mvolved m momturms and un esah atmo radiation esposin-
)
ecceiv d try mdividuals employ *d as ead.ation warhers on a p*rmaiwat ut tempoidsv bsus and *epusme received by momfor*d vis, tors The mlormation maw alsu tw
{
e declosed to en apsuppreair Federat. State.or lural agency
- Itw ewnt itw mformation mdicates a veoistion as potent.e v.ulat.an ut law and m the course of an d
edmmntrative os guditial orot**dmg
- 4. WHETHER DISCLOSURE IS MANDATORY OR V0tuhiARY AND EFFECT ON INDIVIOUAL OF NOT PROV40tNG INFORMAil0N H n vukmtar, noneses tne accasee m st compie'e N AC 8 ord or race *%a for wnom tv out/nsnIne seg aveJ.edyr.a sua mcwo*gsac.a secr.n mbet u
v u
twl ume*1 me.ulnhu, is.pq ' iv i.iart e to PF H 20 70 # F.plure tu ein to ma, wheets alw hsens** to entpecenwi.t artime m accordance with 10 CF R 70 604 The m.at wcm.tv n.outwo s e.1 in 4#
- that N RC t e. ao su m.at.' atentilwe uut whiett to the cumc+m e of smulae ninnn u. tnr*tiates amoms etw f uve nt.*iun.,u al u.n d.no e manHauwd umaly.
t 1
. s SvSnNCIR(St MD ADDRESS D=WUmmem arWam Am U S wa# FWawvCN Weisgiosi 0 C. 20555
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INSTRUCTIONS FOR PREPARATION OF NRC FORM $
! The preparation and safekeeping of this form of a clear and legible items 9, sett. explanatory. The values are to ye given in rem.
raord containmg all the information required on this form es re-10 and All measurements are to be interpreted m the best i
quirrd purmaant to Section 20 401 of " Standards for Peptection 13.
method known and in accordance with Patiegtaph 20.4 tc).
. Agamse Radeation," 10 CF R 20. as a current reco,-d of occupational Where calculations are made to determane dose, a copy of
)f f a ternal radiatson exposures, Such a accord must be maintained such calculations is to be maintained in conjunction with l-for each individual for whom personnel monitor mg is required this record. In any case where the dose for e ca'endar -
Ander Section 20.202. Note that a separate NRC Form 5 is to t:e nuarter as less than 10* of the value pecified en Parearaph used for recordmg en ternal exposure to (1) the whole body:
20.101(a), the phrase "less than 10% may be entered en (2) sken of whole body (3) hands and forearrns; or (4) feet arul
. tieu of a numerical value.
ankles, as provided by flem 5 below, item 12.
Add the values under items 9,10 and 11 for each period Listed oclow by etem are instructions and achlitional information of exposure and record the total. In calculating the
- dnatly pertinent to completing this form.
" Total" any entry less than 10".** may be disregarded.
tiem 13.
The runneng totalis to be maintained on the basis of
. Islentification calendar quarters. Paragraph 20 3(a) (4) defmes calendar it:m 1. Self emplanuory.
uvarter. No entry need be made m this item if only item 2. Seif explanatory except that, sf.indivd>al has no social calendar Quarter radiation doses are recorded in seems 9, security numter, the worrlnone" shall be inserted.
10.11 and 12.
em.'
rI.
etime Accumulated Done (Whole Body) fiOTE: If the licensee choores to keep the individual's
. Occmpationa! Emposure exposure below that permstted in Paragr:ph 20.101(a), items
. Item 5. " Doss so the whole body" shall be deemed to include any 14 through 18 need not be completed. However. in that case dose to the whole body, gonads, active blood formmg the total whole body dose for each calendar quarter recorded organs, head and trunk, or lens of eye. Unless the lenses in item 13 (or item 12 ef quarterly doses are entered en item of the eyes ore protected with eye shields, dose recorried
- 12) should not exceed 1 1/4 rom.
uIva If an individuals exposed under the provisions of Paragraph 20.101 or r hav a ic ness of thr gh a e
300 rng/crtUor less. When the lenses of the eyes are hto (b), complete items 14 through 18 at the end of each calendar quarter and when the sheet is filiad. Values in item 13, when en the of at fr#,170be shieldghaving a tissue equivalent thic ness middle of a calendar quarter, and v61ues in item 18, must be brought D
tected w.h e mg/cm, dose recorded as whole body dose 21'r"f'"d"7a"nW'i.Os@c 'J","fet "'""'
D'E' l'ATo'M5On**o*5rompof NRC
<*ui "I
dose records for the individual (e g from item I Dose recorded as dose to the skin of the whole body hands Form 5 or llem 11 of NRC Form 4) The total occupalonal and forearms, or feet and ankles should include the dose radiation dose received by the ardvidual must be entered delevered through a tessue equivalent absorber having a in thrs stem. Including any occupational dose received thickness of 7 mo/cm? or less. The oose to the skin of from sources of radiation not hcensed by the Commission the whole body, hands and forearms,or feet and ankles if the individual was exposed k sources of radiation not should be recorded on separate forms unless the dose to licensed by t*ie Commission during any Calendar Quarter those parts of the body has been included as dose to the after Comp 6eling NRC Form a and personnel monitoring whole body on a form maintained fur secording whole bodV equipment was not worn by the mdevedual. it should be exposure.
assumed that the individual received a dose of 1 1/4 Item 6. This item need be completed only when the sheet, rs used rems during each such ca6endar Quarter to record whole body emposures and the licensee is
- exposmo the indevedual under the provisions of Paragraph item 15.
Enter the total calendar cuarter dose from item 13 (or 20.101(b) which allows up to 3 rems per quarter to the from item 12 af quarterly doses are entered in item 12) whole body. Enter in this item the unused part of per-and the date designating the end of the calender cuarter missible accumulated dose tak en from previous records of in which the done was received (e.g., March 30,1962).
exposure s e, item 18 of the preceding NRC Form 5 or item item 16.
Add item 14 and item 15 and enter that sum.
t 3 of NRC Form a if the inovedual s exposuee durmg item 17.
Obtain the Permissete Accumulated Dose (PAD) in rem employment with the hcensee Degins with this record for the WHOLE BODY. "N" es equat to the number of years of age of the mdevidual on his last birthday. Suty Item 7. Indicate the method used for monitoring the individual's tract 18 from N and multiply the difforence by $ rem exposure to each type of radiation to whsch he is esposed e g., John Smith, ege 32, N = 32, PAD = 5(32-181 in the course of his dutees Abbreviations may be used.
remd item 8. Doors received over a period c,t less than a ce6endar ouarter item 18.
Determme the unused part of the PAD by subtracting need not be separately entered on the form provided that item 16 from item 17. The unused part of the PAD the licenses maintams a current record of the doses received is that portion of the Lifetime Accumulated Dose for by the individual which have not as yet been entered on the the individual remainmg at the end of the period form. The persod of exposure should specify the day the covered by this sheet.
measurement of that exposure was initiated and the day on which it was termmated. For example if only cuarterly doses are entered, the period of exposure for the first calender quertar of 1962 might be taken as runnina from Monday. January 1,1962, through Friday March 30 1962 and would be indicated in this item as Jan 1,1962 Mar. 30,,
1962. If weekly doses are enteret a film badge issued Monday mornin0, January 1,1962, and pickoo uo F riday January 5,1962, would be indicated as Jan.1,1962.Jan. Ii.
1962.
PRIVACY ACT STATEMENT Pursue il au 5 U S C %2stel(35, enacted mio law tiv pcten 3 of the P mac, Act ut 19 74 (Pubhc tan 93 579), tie Iollowmg stawmma u furnistwa1o md=* ousts who swoog.ntormaten to me Nuciea' Regeatory Commiss.on on NR", f orm 5 t'es.n'owato, e maintainec e a syste'= 08 secoros oes.g reo as NRC.27 ano orscreco et 40 iederal Register 4$344 (Octobei 1.19 75) 1 AUTHORIT Y
$*chons 53. 63. 65. 81.103.104.16 t(bl. and l61lol of ite Atomic E nng, Act of 1954. es amendes t42 0 $ C 2073,2093.2095. 2111. 2133.
2134. 22011b), and 2201:o1) The authos.tv f os schcilmg the Social securit, number es 10 CF A Pari 20
- 2. PRINCIPAL PURPOSE ISI Tre miosmahon a ened be eiw NRC in eis evaluation ut ter nsk of rad stion esposme asws.aied with the hcened actait, and m eartusmg its statutos, respom.behts to momspr and seentate the salat, ancheetth practices of afshcenwes. The data permits a mesmngful comparison of both tm sent and long term espusure esseswnce amons: tviws of bcensees antf ampug licenPes withen each itpse Data on your enoosure to radiat.on is avaiiable to you upon acut r*Quesi 3 ROUTINE USE$
T he inf orm.han me, be used to orovide data to olier F eorial and Siam avances a=oh*d a momtru ms and o' evah.shng eadishon eanosure srceived by individuals emptowed as sad.al.on workers on a poemaewnt aw temposaq basis and esposme feceved by monitored visants Tte mformahon may she tie d.sclose d to an apenure. ate Federat State. os local agency
- the event etw miermation mdicates a veistion ce potent.c violatou of law and m the course of an (dmmestrative or pedicial seos.**d.ng 4 WHITHFR DISCLOSURI15 MANDATORY OR VOLUNI ARY AND EFFECT ON INDIVIOUAL OF NOT Pl40V10tNG INFORMAf tDNli es voluntary mc sag soc.a sece'. ncoei *ioneve, toe.iceasee m st comoie e NtlC 8erm'o9aca ciowua toe w'em me vehnch Ine wontepona iv u
a p*s sania'i munnaio, 4.at) se4 u en*# 1(I fI ff 20 70 7 8 mime to een so nu, whest ti, hcens** to ensurc*nwns arbun m accoidance with 10 CFR 20 601 The m.at mm.t v....mh-i,....s su.... e itut NRC t.e m au ma ut ais.e,.mi whnt he see cumc.d-m r ul
- mile namn m b. ret.c ps amons ste taige MadHhn nl l 48t s+t"L.een chiesp.is it,ild e. 88Jetiisfitid b Sv5TtM MANACIR6p AND ADDRESS D*ccio' * ** ice o' h8ais9ement are Propam Anavsas D $ Nucirar Reguiatory Comfween mshmilton. O C. 205%
_ ______..____________.._ _ _______________ _ _ _ __ _ _ _ _