ML23318A428

OMB 3150-0006, NRC Form 5 (OMB Copy)

ML23318A428
Person / Time
Issue date:	11/21/2023
From:	Terry Brock, John Tomon NRC/RES/DSA
To:
References
Download: ML23318A428 (1)

Text

9B.

9A.

OCCUPATIONAL DOSE RECORD FOR A MONITORING PERIOD NRC FORM 5 (MM-DD-YYYY) 10 CFR PART 20 U.S. NUCLEAR REGULATORY COMMISSION EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB NO. 3150-0006 Estimated burden per response to comply with this mandatory collection request: 20 minutes. This information is used to ensure that doses to individual do not exceed regulatory limits. This information is required to record/

annually report individual occupational exposure to radiation to ensure that the exposure does not exceed regulatory limits. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0006), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

PAGE OF

1. NAME (LAST, FIRST, MIDDLE INITIAL)

2. IDENTIFICATION NUMBER

3. ID TYPE

4. SEX MALE FEMALE

5. DATE OF BIRTH (MM/DD/YYYY)

6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)

7. LICENSEE NAME

8. LICENSE NUMBER(S)

RECORD ROUTINE PSE

20. SIGNATURE - LICENSEE

21. DATE PREPARED DOSES (in rem)

INTAKES 10A. RADIONUCLIDE 10B. CLASS 10C. MODE 10D. INTAKE IN µCi LENS (EYE) DOSE EQUIVALENT (LDE)

SHALLOW DOSE EQUIVALENT, WHOLE BODY (SDE,WB) 13.

SHALLOW DOSE EQUIVALENT, MAX EXTREMITY (SDE,ME) 14.

COMMITTED EFFECTIVE DOSE EQUIVALENT (CEDE) 15.

COMMITTED DOSE EQUIVALENT, MAXIMALLY EXPOSED ORGAN (CDE) 16.

TOTAL EFFECTIVE DOSE EQUIVALENT (ADD BLOCKS 11A AND 15)

(TEDE) 17.

19. COMMENTS NRC FORM 5 (MM-DD-YYY)

EFFECTIVE DOSE EQUIVALENT (FOR EXTERNAL EXPOSURES)

(EDEX) 11A.

ESTIMATE DEEP DOSE EQUIVALENT (FOR THE ENTIRE MONITORING PERIOD)

(DDE) 11B.

12.

TOTAL ORGAN DOSE EQUIVALENT MAX ORGAN (ADD BLOCKS 11B AND 16)

(TODE) 18.

• Note: Social Security Numbers must not be visible on the outside of any package sent by mail.

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE COMPLETION OF NRC FORM 5 (All doses should be stated in rems)

PRIVACY ACT STATEMENT NRC FORM 5 OCCUPATIONAL DOSE RECORD FOR A MONITORING PERIOD Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579),

the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 5. This information is maintained in a system of records designated as NRC-27 and described at 84 Federal Register 71558 (December 27, 2019), or the most recent Federal Register publication of the NRC's Systems of Records Notices that is located in NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2051, 2073, 2093, 2095, 2111, 2133, 2134, and 2201(o); 10 CFR Parts 20 and 34; Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O. 12196, as amended; E.O. 13708.

9A. Place an X in Record, or Estimate. Choose Record if the dose data listed represent a final determination of the dose received to the best of the licensees knowledge. Choose Estimate only if the listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report. An example of such an instance would be dose data based on self-reading dosimeter results and the licensee intends to assign the record dose on the basis of TLD results that are not yet available. If the individual or an organization has indicated that the individual was monitored, but the monitoring records could not be obtained, enter No Record for this monitoring period.

1. Type or print the full name of the monitored individual in the order of last name (include "Jr,"

"Sr," "III," etc.), first name, middle initial (if applicable).

2. Enter the individual's identification number, including punctuation. This number should be the 9-digit social security number if at all possible. If the individual has no social security number, enter the number from another official identification such as a passport or work permit.

3. Enter the code for the type of identification used as shown below:

4. Check the box that denotes the sex of the individual being monitored.

5. Enter the date of birth of the individual being monitored in the format (MM/DD/YYYY).

6. Enter the monitoring period for which this report is filed. The format should be (MM/DD/YYYY -

(MM/DD/YYYY).

7. Enter the name of the licensee.

8. Enter the NRC license number or numbers.

10A. Enter the symbol for each radionuclide that resulted in an internal exposure recorded for the individual, using the format "Xx-###x," for instance Cs-137 or Tc-99m.

10C. Enter the mode of intake. For inhalation, enter "H." For absorption through the skin, enter "B."

For oral ingestion, enter "G." For injection, enter "J."

10D. Enter the intake of each radionuclide in µCi.

11B. DDE - Enter the DDE measured at the highest point on the whole body for the entire monitoring period (e.g.,year - including those time periods when EDEX was being determined using NRC-approved special dosimetry methods).

12. Enter the lens does equivalent (LDE) recorded for the lens of the eye.

13. Enter the shallow dose equivalent recorded for the skin of the whole body (SDE,WB).

15. Enter the committed effective dose equivalent (CEDE).

16. Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ.

17. Enter the total effective dose equivalent (TEDE).

The TEDE is the sum of items 11A and 15.

19. COMMENTS: In the space provided, enter additional information that might be needed to determine compliance with limits. An example might be to enter the note that the SDE,ME was the result of exposure from a discrete hot particle.

Another possibility would be to indicate that an over exposed report has been sent to NRC in reference to the exposure report.

20. Signature of the person designated to represent the licensee.

21. Enter the date this form was prepared.

9B. Place an "X" in either Routine or PSE. Choose "Routine" if the data represent the results of monitoring for routine exposures. Choose "PSE" if the listed dose data represents the results of monitoring of planned special exposures received during the monitoring period. If more than one PSE was received in a single year, the licensee should sum them and report the total of all PSEs.

CODE ID TYPE SSN U.S. Social Security Number PPN CSI Canadian Social Insurance Number WPN PADS Identification Number Other Passport Number Work Permit Number PADS OTH 10B. Enter the lung clearance class as listed in Appendix B to 10 CFR Part 20.1001-2401 (D, W, Y, V, F, M, S, or O for other) for all intakes by inhalation.

11A. Enter the effective dose equivalent (EDEX).

14. Enter the shallow dose equivalent recorded for the skin of the extremity receiving the maximum dose (SDE,ME).

18. Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of items 11B and 16.

2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the risk of exposures to radiation and radioactive materials associated with licensed activities and in exercising its statutory responsibility to monitor and regulate the safety and health practices of its licensees. The data permits a meaningful comparison of both current and long-term exposure experience among types of licensees and among licensees within each type. Data on your exposure to radiation is available to you upon your request.

3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, this information may be used to provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation exposure received by individuals monitored for radiation exposure while employed by or visiting or temporarily assigned to certain NRC licensed facilities; or to return data provided by licensee upon request. Information may be disclosed in accordance with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information, including the Social Security number (SSN) in block #2. The SSN is used to assure that NRC has an accurate and unique identifier not subject to the coincidence of similar names or birth dates among the large number of persons on who data is maintained. The licensee must complete NRC Form 5 on each individual for whom personnel monitoring is required under 10 CFR 20.1502. In addition, licensees must submit this information to NRC in accordance with the requirement under 10 CFR 20.2206. Failure to do so may subject the licensee to enforcement action in accordance with 10 CFR 20.2401.

5. SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection Branch, Division of Systems Analysis, Office of Nuclear Regulatory Research, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.