ML23319A010

OMB 3150-0005, NRC 4 (OMB Copy)

ML23319A010
Person / Time
Issue date:	11/15/2023
From:	Terry Brock, John Tomon NRC/RES/DSA
To:
References
OMB 3150-0005
Download: ML23319A010 (1)

Text

PAGE _____ OF _____

NRC FORM 4 U.S. NUCLEAR REGULATORY COMMISSION (MM-DD-YYYY) 10 CFR PART 20 CUMULATIVE OCCUPATIONAL DOSE HISTORY APPROVED BY OMB NO. 3150-0005 EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 15 minutes. This information is required to record an individuals lifetime occupational exposure to radiation to ensure that the cumulative exposure to radiation 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 email to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0005), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17Street NW, Washington, DC 20503; email: 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.

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

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

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

7. LICENSEE NAME

8. LICENSE NUMBER

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

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

7. LICENSEE NAME

8. LICENSE NUMBER

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

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

7. LICENSEE NAME

8. LICENSE NUMBER

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

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

7. LICENSEE NAME

8. LICENSE NUMBER

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

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

7. LICENSEE NAME

8. LICENSE NUMBER

9.

RECORD ESTIMATE NO RECORD

10.

ROUTINE PSE 11a. EDEX 11b. DDE

12. LDE

13. SDE,WB

14. SDE,ME

15. CEDE

16. CDE

17. TEDE

18. TODE

19. SIGNATURE OF MONITORED INDIVIDUAL

20. DATE SIGNED

21. CERTIFYING ORGANIZATION

22. SIGNATURE OF DESIGNEE

23. DATE SIGNED NRC FORM 4 (MM-DD-YYYY)

• 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 4 (All doses should be stated in rems)

PRIVACY ACT STATEMENT NRC FORM 4 CUMULATIVE OCCUPATIONAL DOSE HISTORY

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 individuals identification number, do not include 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:

CODE ID TYPE SSN U.S. Social Security Number PPN CSI Canadian Social Insurance Number WPN PADS Identification Number Other

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 or facility not licensed by NRC that provided monitoring.

8. Enter the NRC license number or numbers.

9. Place an X in Record, Estimate, or No Record. 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. The individual would not be available for a PSE. For monitoring periods during the current year where records are not available, reduce the individuals allowable dose by 1.25 rems for each quarter for which records were unavailable as required by 10 CFR 20.2104(e)(1).

10. 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.

11A. EDEX - Enter the EDEX for the entire monitoring period (e.g., year). EDEX is the sum of the EDEX component determined using NRC-approved special dosimetry methods (see RG 8.40) and the EDEX component estimated by the DDE for those time periods when not using NRC-approved special dosimetry methods.

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 eye dose 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).

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

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.

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

19. Signature of the monitored individual. The signature of the monitored individual on this form indicates that the information contained on the form is complete and correct to the best of his or her knowledge.

20. Enter the date this form was signed by the monitored individual.

21. [OPTIONAL] Enter the name of the licensee or facility not licensed by NRC, providing monitoring for exposure to radiation (such as a DOE facility) or the employer if the individual is not employed by the licensee and the employer chooses to maintain exposure records for its employees.

22. [OPTIONAL] Signature of the person designated to represent the licensee or employer entered in item 21. The licensee or employer who chooses to countersign the form should have on file documentation of all the information on the NRC Form 4 being signed.

23. [OPTIONAL] Enter the date this form was signed by the designated representative.

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 4. 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.

2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the risk of exposures to radiation and radioactive material 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, 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; and 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 and to assure that there are no missed doses or monitoring periods and an individual gets a complete dose history when requested. 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.

Passport Number Work Permit Number PADS OTH Note: If EDEX has been determined by measuring the DDE (at the highest exposed part of the whole body - see 10 CFR 20.1201(c)) for the entire monitoring period, then box 11a and 11b will have the same value.