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)

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NRC FORM 5 U.S. NUCLEAR REGULATORY COMMISSION EXPIRES: (MM/DD/YYYY)APPROVED BY OMB NO. 3150-0006 (MM-DD-YYYY) Estimated burden per response to comply with this mandatory collection request: 20 minutes. This information is 10 CFR PART 20 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 OCCUPATIONAL DOSE RECORD 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, FOR A MONITORING PERIOD (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

• Note: Social Security Numbers must not be visible on the outside of any package sent by mail. displays a currently valid OMB control number.

1. NAME (LAST, FIRST, MIDDLE INITIAL) 2. IDENTIFICATION NUMBER 3. ID TYPE 4. SEX5. DATE OF BIRTH MALE (MM/DD/YYYY)

FEMALE

6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER(S) RECORD ROUTINE9A.9B.

- ESTIMATE PSE

INTAKES DOSES (in rem) 10A. RADIONUCLIDE 10B. CLASS 10C. MODE 10D. INTAKE IN µCi EFFECTIVE DOSE EQUIVALENT (FOR EXTERNAL EXPOSURES) (EDEX) 11A.

DEEP DOSE EQUIVALENT (FOR THE ENTIRE MONITORING PERIOD) (DDE) 11B.

LENS (EYE) DOSE EQUIVALENT (LDE)12.

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.

TOTAL ORGAN DOSE EQUIVALENT MAX ORGAN (ADD BLOCKS 11B AND 16) (TODE) 18.

19. COMMENTS

20. SIGNATURE - LICENSEE 21. DATE PREPARED

NRC FORM 5 (MM-DD-YYY)

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE PRIVACY ACT STATEMENT COMPLETION OF NRC FORM 5 NRC FORM 5 (All doses should be stated in rems) OCCUPATIONAL DOSE RECORD FOR A MONITORING PERIOD

1. Type or print the full name of the monitored 10A. Enter the symbol for each radionuclide that 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),

individual in the order of last name (include "Jr," resulted in an internal exposure recorded for the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory "Sr," "III," etc.), first name, middle initial the individual, using the format "Xx-###x," for Commission (NRC) on NRC Form 5. This information is maintained in a system of records designated as (if applicable). instance Cs-137 or Tc-99m. 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

2. Enter the individual's identification number, 10B. Enter the lung clearance class as listed in Documents Access and Management System (ADAMS).

including punctuation. This number should be Appendix B to 10 CFR Part 20.1001-2401 (D, W, the 9-digit social security number if at all Y, V, F, M, S, or O for other) for all intakes by 1. AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2051, 2073, 2093, 2095, 2111, 2133, 2134, and possible. If the individual has no social security inhalation. 2201(o); 10 CFR Parts 20 and 34; Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O. 12196, as number, enter the number from another official 10C. Enter the mode of intake. For inhalation, enter amended; E.O. 13708.

identification such as a passport or work permit. "H." For absorption through the skin, enter "B."

3. Enter the code for the type of identification used For oral ingestion, enter "G." For injection, 2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the risk of exposures to as shown below: enter "J." radiation and radioactive materials associated with licensed activities and in exercising its statutory 10D. Enter the intake of each radionuclide in µCi. responsibility to monitor and regulate the safety and health practices of its licensees. The data permits a CODE ID TYPE meaningful comparison of both current and long-term exposure experience among types of licensees and SSN U.S. Social Security Number 11A. Enter the effective dose equivalent (EDEX).among licensees within each type. Data on your exposure to radiation is available to you upon your request.

PPN Passport Number 11B. DDE - Enter the DDE measured at the highest CSI Canadian Social Insurance Number point on the whole body for the entire monitoring 3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, this WPN Work Permit Number period (e.g.,year - including those time periods information may be used to provide data to other Federal and State agencies involved in monitoring and/or when EDEX was being determined using NRC-evaluating radiation exposure received by individuals monitored for radiation exposure while employed by or PADS PADS Identification Number approved special dosimetry methods). visiting or temporarily assigned to certain NRC licensed facilities; or to return data provided by licensee upon OTH Other request. Information may be disclosed in accordance with any of the Routine Uses listed in the Prefatory

12. Enter the lens does equivalent (LDE) recorded for Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in the

4. Check the box that denotes the sex of the the lens of the eye. event the information indicates a violation or potential violation of law; in the course of an administrative or individual being monitored. judicial proceeding; to an appropriate Federal, State, local and foreign agency to the extent relevant and

5. Enter the date of birth of the individual being 13. Enter the shallow dose equivalent recorded for the necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision monitored in the format (MM/DD/YYYY). skin of the whole body (SDE,WB). about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and

14. Enter the shallow dose equivalent recorded for the in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid

6. Enter the monitoring period for which this report skin of the extremity receiving the maximum dose experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to appropriate is filed. The format should be (MM/DD/YYYY - (SDE,ME). persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed (MM/DD/YYYY). breach of data from this system of records.

7. Enter the name of the licensee. 15. Enter the committed effective dose equivalent 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT (CEDE). PROVIDING INFORMATION: It is voluntary that you furnish the requested information, including the Social

8. Enter the NRC license number or numbers. Security number (SSN) in block #2. The SSN is used to assure that NRC has an accurate and unique identifier 9A. Place an X in Record, or Estimate. Choose Record 16. Enter the committed dose equivalent (CDE) not subject to the coincidence of similar names or birth dates among the large number of persons on who data if the dose data listed represent a final determination recorded for the maximally exposed organ. is maintained. The licensee must complete NRC Form 5 on each individual for whom personnel monitoring is of the dose received to the best of the licensees 17. Enter the total effective dose equivalent (TEDE). required under 10 CFR 20.1502. In addition, licensees must submit this information to NRC in accordance with knowledge. Choose Estimate only if the listed dose The TEDE is the sum of items 11A and 15. the requirement under 10 CFR 20.2206. Failure to do so may subject the licensee to enforcement action in data are preliminary and will be superseded by a final accordance with 10 CFR 20.2401.

determination resulting in a subsequent report. An 18. Enter the total organ dose equivalent (TODE) for example of such an instance would be dose data the maximally exposed organ. The TODE is the 5. SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection Branch, Division of based on self-reading dosimeter results and the sum of items 11B and 16. Systems Analysis, Office of Nuclear Regulatory Research, U.S. Nuclear Regulatory Commission, Washington, licensee intends to assign the record dose on the DC 20555-0001.

basis of TLD results that are not yet available. If the 19. COMMENTS: In the space provided, enter individual or an organization has indicated that the additional information that might be needed to individual was monitored, but the monitoring records determine compliance with limits. An example could not be obtained, enter No Record for this might be to enter the note that the SDE,ME was monitoring period. the result of exposure from a discrete hot particle.

9B. Place an "X" in either Routine or PSE. Choose Another possibility would be to indicate that an over exposed report has been sent to NRC in "Routine" if the data represent the results of monitoring for reference to the exposure report.

routine exposures. Choose "PSE" if the listed dose data represents the results of monitoring of planned special 20. Signature of the person designated to represent exposures received during the monitoring period. If more the licensee.

than one PSE was received in a single year, the licensee should sum them and report the total of all PSEs. 21. Enter the date this form was prepared.