ML22200A114

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SEAD3 NRC Personal International Travel Form - Screenshots
ML22200A114
Person / Time
Issue date: 08/23/2022
From:
NRC/OCM
To:
Shared Package
ML22200A110 List:
References
Download: ML22200A114 (6)
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Text

NRC Persona l International Travel Form Privacy Act Statement Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 cf the Privacy Act of 1974 (Public Law 93-579), the fellowing statement is furnished to ind;viduats who suppfy information to the U.S. Nuclear Regulatory Ccmirission (NRC) on the NRC Personal International Travel Form. This informa1ion is mainta:ned in a system of records designated as NRC-39 and described at 84 Federal Register 71568 (December 27, 2019) er in the most recent Federal Register publication cf the NRC- 39 System of Records Notice that is located in NRCs Agencywide Documents Access and Management System.

1. AUTHORITY: 42 u.s.c. 2011 et seq.; 42 u.s.c. 2165, 2201(0, 2201a, and 2284; 42 u.sc. 5801 et seq.;

Executive Orde, (E.0 ,) 9397, as amended by f .O. 13478; f .O. 10450, as amended; E.O. 10865, as ameooed; E.O. 13467; E.O. 13526; E.O. 13587; 10 CFR Parts 10, 11, 14, 25, SO, 73, 95; 0 ,\18 a rc'Jlar No.

A-130, Revised; 5 CfR parts 731, 732, and authorities cited therein.

2. PRINO PAl PURPOSE(S}: For NRC d eared employees and contractors to re-port and receive agency apprC'\lal for personal international travel.
3. ROUTINE USE(S}: Information may be used on a need-to-knew basis by NRC officials, Hearing Examiners, PcrscM el Security Review Panel members, OPM, Q A, and other Federal agencies to determine/ certify clearance or access authc rizatiCJ\ to determine eligibility fer access to NRC buildings or access to Federal automated information systems or data, to mainta'n the NRC personnel security orooram. and to orovide lic ensees criminal history information needed for the r unescorted access er access to safeguards information determinations. Information may also be d'.s dosed: to an appropriate f ederai State, lccal or foreEgn agency in the event the information indicates a violation or potential vio!atic n of law; to NRC-paid experts, consultants, and others under ccntractwith the NRC, on a need-tc -know ba-sts; and to appropriate persons and entities for purposes of response and remedial effoi s in the event of a suspected or confirmed breach of data from ttte NRC-39 system cf records. For detailed disclosure information, please see NRC 39 ~ersonrel Security Fie~ and Associated Records 84 Federal Register 71 552 - 71 568 (December 27, 2019).
4. WHETHER DISCLOSURE IS MANOATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosure is mandatory, Failure to timely report the information ccu!d result in disc*plinaJY action and/or affect e!lg ibility for a security clearance.
s. SYSTEM MANAGER AND ADDRESS: D:rector, Division of f acilities and Security, Office cf AdministratiC{\ U.S. Nudear Regulatory CommlssiOI\ Washington, DC 20555-0001 .

PAPERWORK REDUCTION ACT STATEMENT Approved by OMSNcx 3150-XXXX Expiration Qal e: MWDD/YYYY Estimated burden per response to compfy with th*s mandatory collection request: 15 minutes. This fc rm is U!)Ct.l fo, Uic- IC'l,)t.:Jtil19 Of lCIOffi-t.ic:I fo1dy:11I.Jc:v d Cl!> IC'ljUil c-'-' t,y Uic- Scw1ily Exc-..uUvc- Ay:enl Oi1c-t.li\'C' 3 (SEAO 3). Send com.m ent! !"'='Qarding burden estimate to the FotA, library, and Information Collections Branch (T-6 A1~ . U.S. Nuclear Regulatory Commission, washingtol\ DC 20555-0001 or b/ email to lnfcCollects.Resource@nrc.gov, and to the OMS reviewer at: 0 MB Office of Information and Regulatory Affairs (3150-XXXX) Attn: Desk Officer for the Nudear Regulatory CommlssiOI\ 725 17th Stree~ NW Washington, DC 2)503; email: oira_submiss1on@c mb.eop.gov, The NRC mey not conduct er sponsor, and a person is oot required to respond to, a request for information er a.n information coltection requirement unless the requesting document displays a currently valid 0 MB control number, By submitti"tg this fc rm, you ackoowledge that you have read and understand the aforementioned Privacy Acl

Fi rst Name

  • Last Name
  • Date of Birth
  • First Name Last Name Date of Birth

~ Trip Info rmation Departu re Date

  • G Return Date
  • G Re-Entry to U.S
  • G MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY Purpose *

/,

Are you traveling with companions?

  • G Yes No Add Passport Passport Number
  • Passport Number Expiration Date
  • MM/DD/YYYY Issuing Authority *

~ Trip Information Add foreign countries that will be visited on this trip.

Ill Passport Information 0 Foreign Countries

~ Travel Itinerary

  • IHIMI Unite~

ft Lodging 1

United Arab Emirates

~.,,. Acknowledgement United Kingdom Ac.-- .. ,_.,~ .... , .. ~~~"~***~*~* *~* ---.. ,-,, ~* ,s.Jur trip, including layovers.

D Lodging Add all known accomm::idations for your t rip.

Add Lodging X Lodging Type

  • V Address Line 1
  • Address Address Line 2 City
  • State/Province/Region
  • Zip/Postal Code
  • Country
  • Check In
  • Check Out
  • 0 MM/DD/YYYY MM/DD/YYYY

City

  • State/Province/Region
  • Zip/Posta l Code
  • Country
  • Chec k In
  • Check Out
  • 8 MM/DD/YYYY MM/DD/YYYY Contact Phone Number
  • Reference ID
  • 8 Reservation Number or Confirmation Detai ls

- Add Lodging Depa rture Da te

  • MM/DD/YYYY Arrival Dat e
  • G MM/DD/YYYY Mode of Tra nsporta t io n
  • Fro m City
  • From City To City
  • To City Refere nce ID
  • G Servicer, Flight, Reservation, or Ticket Number

~ Trip Information la! Passport Information 0 Foreign Countries

.~ Acknowledgement

~ Travel Itinerary I have reviewed travel restrictions and safety Date Ill Lodging measures and determ ined that I am able to 05/06/2022

£" Acknowledgement travel. I agree to follow all COVID-19 travel requirements and NRC re-entry requ irements.

  • Yes No 1111
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