NRC Generic Letter 1985-08
TO ALL HOLDERS OF CONSTRUCTION PERMITS AND OPERATING LICENSES
SUBJECT: 10 CFR 20.408 TERMINATION REPORTS - FORMAT
GENERIC LETTER NO. 85-08 Pursuant to 10 CFR 20.408, licensees are required to submit to the NRC a report of each individual's exposure to radiation and radioactive material when the individual terminates employment or work assignment at their facility. These exposure reports are commonly referred to as §20.408 termination reports.
Previously, we have not specified a preferred reporting format for compliance with this regulation. However, the NRC is currently receiving approximately
100,000 termination reports each year, and this number is steadily increasing.
For purposes of efficient automatic data processing, it is important to use a standard format. Processing in a more timely fashion will make the data more useful to the NRC and others in their performance of various duties (see Enclosure 1).
For future §20.408 termination reports we request that you voluntarily use the attached Standard NRC Form-439. Instructions for completing the form are attached to the form. Questions regarding these instructions should be directed to Barbara G. Brooks, Office of Nuclear Regulatory Research, Washington, D. C. 20555,
(301) 427-4577.
The NRC is also conducting a pilot program for the electronic transmission of the termination data to the NRC via computer tapes or by direct linkup to the NRC's computing facility, and we would like to encourage you to consider participating. Should you desire more information about this program please contact Ms. Brooks.
The form is intended for use in connection with the information collection requirement established in Section 20.408, 10 CFR Part 20 and approved under OMB Clearance Number 3150-0014.
ompson, JN*, Dir or o viion of Licensfng /g1/
O ce of Nuclear Reactot egulation Enclosure:
1.Ues-of Radiation Exposure Data I
2. Five copies of NRC Form 439 c Li t tflenercilel;1ers - g>
8505210106 PDQI A-DOCK O500L
Uses of Radiation Exposure Data A number of NRC licensees have inquired as to how occupational-radiation NRC staff.
exposure data (from reports required by the NRC)'are used by themany affected This is a very appropriate inquiry that may be of importance' to principal licensees. In combination with other sources of information, the uses of the data are to provide facts regarding routine occupational VW with exposures to radiation and radioactive material that occur in connectiondoses NRC-licensed activities, including individual and collective radiation the inhalation of from external sources as well as pertinent information on exposure magnitude, radioactive material (nuclides involved, bioassay results, etc.) These facts are used by the NRC staff as indicated below:
1. The external-dose data permit evaluation of the'radiological ofrisk the associated with NRC-licensed activities, including the size workforce and the collective dose.
2. The data permit evaluation, from the viewpoint'of trends, of theand ALARA
effectiveness of the overall NRC/licensee radiation protection efforts. They also provide for the identification (and subsequent correction) of unfavorable trends.
transient-
3. The data provide for governmental monitoring of the potential worker problem.
the utilization
4. The data are used in the establishment of priorities for of NRC health physics resources: research, standards development, regulatory program development.
that are
5. The data are considered in reviews of inspection frequencies programmed for various categories of licensees.
6. Licensing action decisions are often influenced by the data.
7. The data are used for comparative analyses of radiation protection plant by plant, performance: US/foreign, BWR's/PWR's, civilian/military, nuclear industry with other industries, etc.
8. The data permit analysis of annual dose distribution changes which can trigger investigations as to the cause.
9. The data are used for purposes of justification inthe annual budget process.
10. The data provide facts for evaluating the adequacy of the current risk-limitation system (e.g., are individual lifetime dose limits, worker population collective dose limits, requirements for optimization, etc.,
needed).
1
11. The effectiveness of dose-reduction measures is evaluated using the data (e.g., methods for reducing individuals doses that may increase collective dose). the
12. The data provide facts for answering Congressional and Administration inquiries and for responding to questions raised by groups, special interest groups, labor unions, etc. public interest
13. The data permit comparisons of occupational radiation risks potential public risks when action for additional protection with public involves worker exposures. of the
14. The data provide information which can be used in the planning epidemiological studies.- of With regard to routine work-place conditions, the annual statistical summary reports required by 20.407, the termination reports required the annual dose data reported by work function in accordance by §20.408, and
6.9.1.5 of the standard technical specifications for nuclear with Subsection provide the only centralized data base available to assist power plants the performance of its duties as listed above. It is to everyone's staff in the these duties are performed by a well-informed staff in the advantage if information. light of factual
2
U.S. NUCLEAR REGULATORY COMMISSION I- DATE Of REPORT
NRC FORM 419
10 CFR im0 401
2 NRC UCENSE NUMBERIS)
REPORT OF TERMINATING INDIVIDUAL'S
OCCUPATIONAL EXPOSURE
SEE THE ATTACHED INSTRUCTIONS.
PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA
3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OFINDM4DUAL flet. wmd k"a lest) AND ADDRESS Wtionafi B. NAME AND ADDRESS OFEMPLOYER. IFOIFFERENT FROM ABOVE 1tonafl
. SOCIAL SECURITY NUMBER l a DATE OF I MONTHI DAY I YEAR
m BIRTH
PART 11. EXTERNAL DOSE DATA
18 PERSONNEL MONITORING FOREXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.
DEEP WHOSHALLOW Iskint It REMITY OM
KIm
9. PERIODISI OF EXPOSURE
b. NEUTRON c. TOTAL d. BETA SHALLOW bk~mf teerlust date Am)t TOTAL
PART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
12. PERSONNEL MONITORING FOREXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.
18. BIOASSAY RESULTS 17. DOSE ESTIMATES 1rms)
13. INTAKE
13. PERIODISI OFEXPOSURE a. COM b. ANNUAL c. ORGAN IMPC-Hre.1 AiateAlt U NUCLIDE
14 15. FORM a.IN VIVO InCil It. URINALYSIS
Li MITTED DOSE
fefetis.,I RESULTS I
IlI BURDEN 121ORGAN DOSE
19. OTHER BIOASSAY RESULTS
CFR 19.13. CHECK THE FOLLOWING BOX.
2. IFTHIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF10
10 CFRPert 19. Yu should Prserv rho report far fue mrefrmce YES (Thi report 6 Awrnd to vou uider the provaion of Ite Nucfu RepuYtwy Commdersua regulatmon
INSTRUCTIONS FOR COMPLETING NRC FORM 439, Report of Terminating individual's Occupational Exposure exposure reports If you re licensed by die U.S. Nuclear Regulatory Commission (NRC) as specified in 20.40U(a). 10 CFR Pan 20. you are required to submit termination radiation is sobe taken from on eetain individuals to the Director. Oflice of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information standards for die whole dose records that miest be maintained under 120.401 for individuals likely to receive exposure to radiation that exceeds a certain percentage of the NRC dose body, skin or extremides-25% for workers of age IS years or more. 5% for workers younger than IS. The term "individua'" is used below to represent the worker for whom this
"dose equivalent"
report is submitted. The term "dose" as used in Form 439 and in these instructions refr to the dose in rems as defined in g20.4wa) and subsequently designated in ICRU Report 1 (1968). The time to be covered by this report is that period of employment, or work assignment in your facility(s), which ended with the most recent termination
"Termination" is and was at interrupted by any previous termination during which personnel monitoring was required by 120.202(a) and/or bioassays were required by your license.
are clearly identified as defined in 120 3(X 19). Pans 1 and MIof this form reflect regulatory requirements as well as requests intended to standardize reporting methods, requests such.
PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATA
applicable. Enter the This pan identifies the licensee submitting the report and the terminating Individual. It must be completed even if only one of the renaining Parts of this form is fowing data:
ITEM NUMBER
Date that the report was prepared.
2 Current NRC license nunber assigned to the facilitylsl in which the individual received the repored dose. If more than one license Is Involved, enter the license sunber for the facility or activity under which most of the dose was incurred as the first number. If this is not practical. enter the license numbers in the order of original issuance.,
3 Name and address of your facility as it appears on your NRC license.
4 The individual's first name. middle initial. and surname. (Address of the individual may be included. but is is not entered into the NRC records system.)
5 The name and address of the individual's empoloyer. if it is different from the reporting licensee. (Optioal; ot entered into the NRC records system.)
6 The individual's social security number: if not available. enter the word "unkown."
7 The bIdividual's dat of birth.
PART 11. EXTERNAL DOSE DATA
thedose to the sin of For the purpose of this form. the deep dose is defined asthe dose tasesed at tissue depth of 300 or 1.000 mg/cm' (or less). the shallow dose is defined as any part of the body. and the extremities are defined as hands and forearms. feet and ankles.
Item Number 8 If the individual was not monitored for external exposure to radiation. you we requested to check the box to the left and go to Part 11.
LT.JLUViZ1J VGUJIvwrJE
use an-
9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your ficility(s) pursuant to 520202 You are requeted to nual increments-up to the year of termination nd increments an to exceed one quarter for die year in which the individual terminated:
ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (eig. May 1979) and indicate the year only for subsequent annual Increments.
QUARTER: For each eompleted qlarter or bheyear of termination, indicate the quarter and year by date;
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (month, day. year);
Enter the following data:
Ith Unless the eyes are hielded, enter the deep dose nsed at a tissue depth of 300 mg/mn (lmens depth) or less. If the eyes are protected by shielding which has a tissue equivalent thickness of 700 mg/cm' or more, the deep dose may be assessed nt 1000 mg/cm' (gonad depth) or less. Enter the total dose of record I.e.. the highest dose received at the selected depth from all types of external radiation sources, at any location on the body except the skin and the extremities (hands and forearms feet and ankles).
IOc For anlskin areas, except that of the extremities, enter in column lc the shallow dose of ecord. Record the tots dose to the akin, Le.. the highest dose delivered by all radiation Incident on the skin, icluding non-trivial doses from skin contamination, which petates to the depth at which the shallow dose is determined. The dose at a depth of 7 mg/tcm or less, averaged over I emn,is acceptable. If Column I0c is left blank, it will be assumed that the entry in lOs is applicable also fr the shallow dose. Therefore, an entry for shallow dose is required only if It exceeds the deep dose.
l'b & d You re o enter in column llb the contribution made by neutron radiation to the dose reported in Column IOs. and to enter in Column lOd the eoetributw1iin&by bets radiation to the dose reported in Column lMc. Enter XXX if it is known dot there was no exposure to radiation of the type specified in the column beading. Enter UNK If a detectable exposure is reported in Ita or lOc which could have Included a beta or neutron contribution of unknown magnitude.
lo a 11 You we leted to enter m or zero (in each column of 10. or in II) if the dose was undetectable. i.e.. the radiation to hich the worker's dosimeter was exoed peuda response that you considered to be statistically indistinguishable from the response cae by inherent variabilities of the dosimeter the system. Note: It is sometimes required to add m (or Its equivalent) to a teal number; although NRC regulations do not speciy a summation procedure.
NRC staff arbitrarily assigns 10 nirems to be a value of mn(assuming 0.5 L ( 10 4 L. where L is the detection limit) for the purposes of statistical andyses.
-I Reporting of the extremity dose is required. You are equetd to comply in the following manner. Enter the dose of tecord, i.e.. the highest dose.
averaged over any area of I cm'. determined for the iOFFe hands nd forearms or feet and anles during the reported period. It is unnecessary to speciy the extremity that received he dose; doses to different extremities should not be added together. The dose is to include that delivered by all ndia- tion incident on the skin. including non-trivial doses from in contamination. which penetrates to the depth at which tie shallow dose isdetermined. he
5 dose at depth of 7 mgfcm or less ih acceptable. If Column II is lft blank. it will be assumed that the entry in l0c is applicable also for the extremity dose; an entry in Column II is required only if the hiallow dose exceeded the deep dose.
PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
required to submit ter- If you ae licensed by die NRC as specified In pO.408(ai. 10 CFR Part 20. nd if your license requires bioassay services for workers et your facility. you are compliance with mination reports on personnel exposures to radioactive material. contaning information that you have obtained In compliance with the license and' recorded in in compliance V20.401. You ae requested o include in each termination report information that you have obtained in compliance with 120.103(aX31) and 20.103(cX2) and recorded of the reporting with p20.40l. This part provides for the reporting of internal monitoring procedures in terms of bioassay results, dose estimates, or intake. Any one (or more)
material" is used in con- methods may be ued. The term "individual" is used below to represent the worker for whom this report is submitted. The term "exposures to radioactive ntection with these termination reports to represent the entry of radioactive material inito the body.
item Number 12 If the individual was am monitored for exposure to radioactive material. you re to check the box n the left; etherwise. enter the following dat:
Column Number 13 If bioassay results re reported (Column 161,you are M te to ate Jfollowing format. Summarize by year. separately listing the mumber or measurements which Indicated quantities or e ion s Mthiswere undetectable. i.e.. in the detection system used. the mdionuclide present (if any) pro- duced a response that you considered to be statistically indistinguishable from its bsckground. In Column 13 enter each year bioassay was performed, in- eluding the year of termination. In Columnas 14 through 16. ae two lines for each year, as in the example shovn below, die upper line for detectable in results and the lower line for those undetectable. In 16a and/or 16b: spprline. enter the number (including ero) of detectable measurements followed parenthesis by the highest verified result. if any; lower line, enter deue r finincluding eero)of mesurements indicating undetectable amounts.
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continuedl COLUMN NUMBER
13 WContinuedl Column 13 Column 14 Column 1 Coluhnm 16
16a(1l 1621 Itib (pCUL)
1932 U-nat 1 0 luns 2l)
2 lung 10
19S3 U-nat(Th 2341 1 It71 luns 4(61 I lung S
19S4 U-nat(Th 2341 1 21141 lung 12431
0 lung 0
Units for the numbers in parenthesea shown in Column I6b are to be ipecified in the heading for Column lob. If Columns 17 or IP are completed. nota- tions in Column 16 armunnecessary.
If the dose commitment 150-year integrated dosel is reported. indicate in Column 13 by beginning and ending dates (month, day. year) the period during which the associated radioactive material was taken into the body.
If annual doses are reported. enter in Column 13 the calendar year over which each dose was integrated. including the first and any succeeding yearn of this employment or work assipnmet and the year following the termination date.
For entrie in Column IS intakel. specify the reporting intervals Iperiods of exposure) during which the individual was exposed to concentrations of radioactive material. using annual increments up to the year of termination and increments not to exceed one quarter for te year in which the individual terminated. The periods of exposure for intakes should appear as follows:
ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e g.. June 19f3) and indicate the year only for subsequent annual increments.
QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by date.
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (month, day. year.
Reported intakes which include only the quantities required to be assessed in accordance with 120.103(aX3) are acceptable.
14 Identify the symbol used in 10 CFR Part 20. Appendix S. for the radionuclide or mixture of radionuclides for which in vivo and/or urinalysis measuremtents were performed (e.g.. Co 6D. U 2351. If the measured quantity of activity for one radionuclide is also used to estimage quantities. identify the radionuclide actually measured in parentheses immediately slter die radimonuclide listed in Coluns 14. See the other radionuclide example given is the directions for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tn
234 phoon=s
15 Enter die fonts. S for soluble or I for insoluble. of die radionuclide to which the worker was exposed. If unknown. use quotes around dicating which concentration value in Part 20. Appendix S. Table 1. Columa I. was assumed to apply. the leter thus in
16 17 & IS These columns allow for the reporting of the results of the internal monitoring procedures in terms of bioassay results, or dose estimates, or intake. You may use one or more of these methods.
l6a4 I)& d21 For each year during which in vivo measurements were performed. as shown in Column 13. enter in Column 16.a41the number of detectable measurements followed by the highest verified result (in nancocuries) in parentheses. On the next line in this column. enter the number of measurements that indicated undetectable amounts. Specify in Column 16.2) the organ in which the indicated radionuclide was found. Se the example for Column 13. given in the directions
16b First. enter the gravimetric or radiometric unit in which the urinalysis results are reported te.g.. micrograms per liter. nanocuries per liter) in the blank space of the heading for Column 16b. Is Column 16b. for each year during which urinalyses were performed. enter die number of detectable result followed by the highest nurnerical value of the concentration in urine of the radionuclide listed in Column 14 for the year specified in Column 13. On the next line in this column. enter the number of measurements indicating undetectable amounts. See the example given in the directions for Column 13.
17a. b. A c Specify in Column 17c dte organ or tissue receiving doses esthiated in Column 17a or 17b. (Note thdt it is not necessary lo provide both the commnitted and annual doses.) For Columns 17a and 17b you ar requested to follow dut procedures below: if ay alternative procedures are used, describe the.n on die back of this fora. In 17a. enter the dose integrated from t to 50 years. where t is the beginning date shown in Column 13. In
17b enter the dos in- tegrated over each calendar year shown for this purpose in Column 13. Include the Arst and ny succeeding years of this employment or work assignment and the year following tde termination date. Base dose estimates on the quantity las a minimuni of the radionuclide. Column 14.
taken into the body at your facility~s) during this employment or work-assignment period.
18 Reporting of radionuclide intakes. as determined by air sampling. is not required by 10 CFR 20409. However. should this option be chosen, indicate the time-weighted concenrations of radioactive material (i.e.. MPC-hourni to which the individual was exposed during the time periods indicated in Column 13.
Refer to the lan paragraph of the instructions for Column 13 for the time intervals to be used. Complete Columns 13. 14. and 15 for each entry in Column
1l.
Itets number 19 Any bioassay results that cannot be reported as described above should he entered here.
Itern number 20 If you wish to send a copy of this report to the terminating individual to ataisfythe notification requirement of 10 CFR 19.13. check the "Yes" box.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552alel31. enacted into law b ection 3 of the Privacq Act of 1974 (Public Law 93-5793. dte following statement is furnished to individuals and persons who supply information to the Nuclear Regulatory Commission on NRC Form 439. This information ismaintatined in a system of records designated as NRC-27 and described at 40
Federal Register 45344 (October 1. 1975).
1. AUTHORITY. Sections 53. 63. 65. 81. 103. 104. 1611bo. and 161tol of the Atomic Energy Act of 1954. as amended (42 U.S.C. 2073. 2093. 2095. 2111. 2133. 2134.
2201(b). and 2201(o1l. The authority for soliciting the social security number is 10 CFR Past 20.
2. PRINCIPAL
PURPOSE
ISl. The information is used by the NRC in its evaluation of the risk of radiation exposure associated with thd licensed activity and in exercising its statutory responsibility to monitor and regulate the safety and health practice of its licensees. The data permit a meaningful comparison of both current and long-tern ex- posure experience among ypes of licensees and among licensees within each Vpe. Data on your exposure to radiation are available to you upon request
3. ROUTINE USES. The information may be used to provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation exposure received by individuals employed as radiation workers on a perianent or temporary basis and exposure received by monitored visiton. Mte information may also be disclosed to as ap- propriat Federal. Stats. or local agency in the event the information indicate a violation or potential violation of law and is the course of an administrative or judicial proceeding.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION
ON INDIVIDUAL OR PERSON. It is voluntary dot you frnish the requested information. including nane, dame of birth. and social security number. The social security number is used to assure that NRC has an accurate identifier not subject to the coincidence of similar names or birth datr among dte large number of persots on whom damn is maintained. Please note. however. t licease must file a termination report containing tertain required information, such as social security number. for each individual the wvhosemploymnent or work assignment has terminated and for whomtpersonnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the informatdon under 10 CFl 120.202 and 20.403 may subject the licensee to enforcement action under 10 CFl 20.601.
S. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nuclear Regulatory Research U.S. Nuclear Regulatory Cotmmimin Waishingt. DC 20555
NRC FORM 41 U.S. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT
_20.4__
10CFR
REPORT OF TERMINATING INDIVIDUALS 2.NRC UQCENSE NUMBER4SI
OCCUPATIONAL EXPOSURE
SEE THE ATTACHED INSTRUCTIONS.
PART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA
3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDIVIDUAL fNit. myide it. AtP AND ADDRESS ktpeNoal)
5. NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE 1006onafl
6. SOCIAL SECURITY NUMBER I MONTH I DAY I YEAR
7. DATE OF
BIRTH
PART II. EXTERNAL DOSE DATA
18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.
9. PERIODISI Of EXPOSURE DEEP WHOLE BODY
10 SHALLFW t i. AndEXTEMITY DOSE
- s OTAL
ia. TOt b. NEUTRON c. TOTAL d. BETA SHALLOW
PART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
l12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.
16. BIOASSAY RESULTS 17. DOSE ESTIMATES tmot
13. PERIDDISI OF EXPOSURE lB. INTAKE
dt fEPU 1.PRIOD
U. NUCLIDE 15 FORM a. IN VIVO InMC b. URINALYSIS S. COM- b.ANNUAL c. ORGAN IMPC NHr.l Is. II - ESULTS I LI MITTED DOSE
I. BURDEN 121ORGAN DOSE
19. OTHER BIOASSAY RESULTS
20. IF THIS REPORT IS BEING USED TO SATISFY THENOTIFICATION REOUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.
l YES (This reot li fumfhe to you wider It pmovxW of the Nuclear R09latorY Cog-mscrna raguanon 10 CfR Pot 19. You aliould beaerw Ol report Do Arrow ,rfwnca.I
INSTRUCTIONS FOR COMPLETING NRC FORM 439, Report of Terminating Individual's Occupational Exposure If you are licensed by the U.S. Nuclear Regulatory Commission (NRCI as specified in 120.40(a1). 10 CFR Pan 20. you ae required to submit termnination radiation exposure reports on certain individuals to the Director, Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Comnmission. Washington. DC 20555. This information is to be taken from dose records that aust be maintained under 120.401 for individuals likely to receive exposure to radiation that ex sa certain percentage of the NRC dose standards for the whole body. skin or extremties-25% for workers of age IS years or more. 5% for workers younger than IS. The term "individual" is used below to represent the worker for whom this report is submitted. The term "dose" as used in Form 439 and in these instructions refers to the dose in rems as defined in 120.44a1 and subsequently designated '"dose equivalent"
in ICRU Report I (1968). The time to be covered by this report is that period of employment. or work assignment in your facility(s), which ended with the moat recent termination and was not internupted by any previous termination during which personnel monitoring was required by 120.202(a) and/or bioassays were required by your license. "Termintion" is defined in 520.3(a)(19). Parts 1 and 11lof this form reflect regulatory requiremnents as well as requests intended to standardize reporting methods- requests re clearly identified as such.
PART 1 LICENSEE AND INDIVIDUAL IDENTIFICATION DATA
This pail identifies the licensee submitting the report and the terminating individual. It must be completed even if only one of the rernaining Parts of this form is applicable. Enter the following data:
ITEM NUMBER
I Date that the report was prepared.
2 Current NRC license number assigned to the facility(s) in which the individual received the reported dose. If nore than one license is involved, enter the license number for the facility or activity under which most of the dose was incurred as she first mumber. If this is not practical, enter the license numbers in the order of original issuance
3 Name and address of your facility as it appears on your NRC license.
4 The individual's first nare, middle initial. and surname. (Address of the individual may be included, but st is ntl enered into dhe NRC records system.I
5 The nameand aldress of the individual's employer, if it is different from the reporting licensee. (Optional: not entereod into the NRC records system.)
6 The imdividual's social security number. if not available, enter the word "unknown."
7 The individual's dare of birth.
PART 11. EXTERNAL DOSE DATA
For tie purpose of this form, the deep dose is defined as the dose assessed at a tissue depth of 300 or 1.000 mg/cm' (or less), the shallow dose is defined as the dose sothe skin of any pat of the body, and the extremities ae defined as hands and forearms, feet and ankles.
Item Number 3 If the individuall was nt monitored for external exposure to radiation, you arequested Socheck the box to the left nd go to Part 11.
COLUMN NUMBER
9 Specify the reporting intervals (periods of exposure) that the individual was mmnitored at your facility(s) pursuant to 320.202. You arequesed to use n- sual increments up to the year of termination and increments not to exceed one quarter for the year in which the individual terminated:
ANNUAL: Indica the month and year of the beginning date of exposure wheq showing annual increments (e.g., May 1979) and indicate the year only for t annual incremes.
QUARTER: For each completed quarter of the year of tennination. indicate the quarter and year by date:
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (month, day, year):
Enter the following data:
itk Unless the eyes are uhielded, enter the deep dose assessed at a tissue depth of 300 mg/cm' (lens depth) or less. If the eyes aer protected by shielding which has a tissue equivalent thickness of 700 mg/cmz or more, the deep dose may be assessed at 1000 mg/cm' (gonad depth) or less. Enter the total dose of record. ie., thc highest dose received at the selected depth, fromn all types of external radiation sources, at any location on the body except the skin and the extremities (hands and forearms fem and ankles).
lOc For all skin areas, except that of the extremities, enter in column 10c the shadlow dose of record. Record die toud dose to the skin, i.e., the highest dose delivered by all radiation incident on the skin, including non-trivial doses from skin contamination. which penetrates to the depth at which the shallow dose is determined. The dose at a depth of 7 mgicm' or less, averaged over I cm', is acceptable. If Column 10 is left bank, it will be assumed that the entry in l~a is applicable also for the shallow dose. Therefore, an entry for shallow dose is required only If it exceeds tie deep dose.
l0b & d You are MsEy! to enter in column ltb the contribution made by cutron radiation ea the dose teported in Column la. and to enter in Column ltd the eontribution bna by betl radiation to the dose reported in Column 10c. Enter XXX if it is known that tbhre was no exposure to radiation of the type specified in the column heading. Enter UNK if a detectable exposure is reported in l0a or 10c which could have included a beta or neutron contribution of uvknown magnitude.
10 Ik11 You are tequeste toenter m or zero (in each column of 10, or in I1) if the dose was undetectable, i.e., the radiation to which the worker's dosimeter was exposed pic a response tdat you considered to be statistically indistinguishable from dte response cused by inherent variabilities of the dosimeter system. Note: It is sometimes required to add m (or its equivalent) to a real number, although NRC regulations do sot specify a summation procedure. the NRC staff arbitrarily assigns 10 mrems to be a value of m (assuming 0.5 L ( 10 ( L where L is the detection limit) for the purposes of statistical analyses.
Reporting of the extremity dose is required. You are to comply in the fotohwing manner Enter the dose ot ccord. i e, the highest dose.
averaged over any area of I am', determined for the skiliolhe hands and forearms or fet andankles during the reported period. It is unnecessary Io specify the extremity thai received Ate dose: doses to different extremities should not be added together. The dose is to include that delivered by all ria- tion incident on the skin, including nonmtrivial doses from skin contamination, which penetts to the depth at which due siallow dose iadetermined. The dose at a depth of 7 mnglem' or less is acceptable. If Column II Is left blank, it will be assumed tust the entry in 10c is applicable also for the extremity
- dose fanentry in Cohumn II is required only if the shallow dose exceeded the deep dose.
PART I. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
If you are licensed by the NRC as specified in 320.40S(aj. 10 CFR Part 20, and if your license requires bioassay services for workers at your facility. you are required to submit tcr- mination repr on peraonnel exposures to radioactive material, containing information that you have obtained in compliance with die license and recorded in compliatnce with
§20.401. You are s to include in each tennination report information that you have obtained in compliance with 20. 103(a)3) and 20.103(ct2) and recorded in compliance with 120.401. This part provides for duereporting of internal monitoring procedures in tenns of bioassay results, dose estimates, or intake. Any one (or more) of these reporting methods may be ued. The term "individual" is used below to represen the worker for whom this report is submitted. The term "exposures to radioactive material" is used in ctn- suction with these termination reports to represent the entry of radioactive material into the body.
Item Number 12 If the individual was xx monitored for exposure to radioactive material. you are to check the box to die left: otherwise, enter the following data:
Column Number 13 If bioassay results are reported (Column 16i, you are M S! to use the following format. Surnmarize by year. separately listing the number of masufletnents which indicated quantities or concentrations that were undetectable. ie., in the detection system used. the radionclide present (if any) pro.
duced a response thut you considered to be statistically indistinguishable from ha background. In Column 13 enter each year bioassay was performed. in- eluding the year of termination. In Columns 14 through 16. use two lines for each year. as in the example shown below. the upper line for detectable results and the lower line for those undetectable. In 16a and/or 16b: pper line. enter the number (including Mero) of detectable Measurenients followed in parenthesis by the highest verified result, if any; lower line, enter am number (including zero) of measurements indicating undetectable armounts.
INSTRUClIONS FOR COMPLETING NRC FORM 439 (ContiI
COLUMN NUMBER
13 (Continued) Column 13 Column 14 Column 15 Column 16
16d l l 166l21 lt~b (pCit
1982 U-nat 1 0 lung 2(1
-2 lung 10
19S3 U-nattTh 2341 2lC? lung 4463 I lung S
1984 U-natfih 234 1 2041 lung 124133
0 lung 0
Units for the numbers in parentheses shown in Column 16b are to be specified in the heading for Column 16b. If Columns 17 or IS are completed. nota tions in Column 16 are unnecessary.
If the dose comminment (50-year integrated dose) is reported, indicate in Column 13 by beginning and ending date imonth. day. yearl the period during which the associated radioactive material was taken into the body.
If annual doses are reported, enter in Column 13 the calendar year over which each dose was integrated, including the first and any succeeding years of this~employment or work assignment and the year following the termination date.
For entries in Column 1 lintake). specify the reporting intervals (periods ot exposure) during which the individual was exposed to concentrations of radioactive material, using annual increments up to die yea of termination and increments not to exceed one quarter for the year in which the individual terminated. The periods of exposure for intakes should appear as follows:
ANNUAL: Indicate the month and year of the begitming dae of exposure when showing annual increments (e.g.. June 1983) and indicate the year only for subsequent annual increments.
QUARTER: For each completed quarter of the year of termination, indicate the quarter and year by date.
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (month, day. yearl.
Reported intakes which include only die quantities required to be assessed in accordance with 120103(ax3) re acceptable.
14 Identify the symbol used in 10 CFR Patn 20. Appendix S. for the radionuclide or mixture of radionuclides for which ih vivo and/or urinalysi measurements were performed (e.g.. Co 60. U 2353. If the measured quantity of activity for one radionuclide is also used to estimate other radionuclide quantities. identify die radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in the directions for Column 13 where U-nat(Th 2342 is entered in Column 14 indicating that the uranium lung burden was determined fron measurements ofTh
234 photons.
Is Enter the form. S for soluble or I for insoluble, of the radionuclide to which the worker was exposed. If unknown, use quotes around the letter. thut in- dicating which concentration value in Pan 20. Appendix B. Table 1. Column 1. was assumed to apply.
16. 17 At IS These columns allow for the reporting of the results of the internal monitoring procedures in term of bioassay results. or dose estimates, or intake. You may use one or more of dese methods.
Mall &ad(21 For each year during which in vivo measurements were performed. as shown in Column 13. enter in Column 16all) the number of detectable measurements followed by the highest verified result (in nanocuriesi in parentheses. On the next line in this column, enter the number of measurements that indicated undetectable amounts. Specify in Column 16at2) the organ in which the indicated radionuclide was found. See the example gives in tde directions for Column 13.
16b First, enter the gravimetric or radiometric unit in which the urinalysis results are reported (e.g.. micrograms per liter. ntocuuies er liter) in the blank space of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the number of detectable results followed by the highest numerical value of the concentration in urine of the radionuclide listed in Colutn 14 for the year specified in Column 13. On the next line in this column, enter the number of measurements indicating undetectable amounts. See the example given in the directions for Column 13.
lb7. b. A c Specify in Column 17c the organ or tissue receiving doses estimated in Column lb7 or 17b. (Note that it is not necessary to provide bot the committed and annual doses.) For Columns I7b and 17b you we requested to follow the procedures below: if any alternative procedures are used, describe them on the back of this form. In 17a. enter the dose integrated from t to 50 years. where t is the beginning date shown in Column 13. In 17b enter the dose in- tegrated over each calendar year shown for this purpose in Column 13. Include the frst and any succeeding yeats of tits employment or work assignment and the year following the termination date. Base dose estimates on the quantity (as a minimum) of the radionuclide. Column 14. taken into the body at your facilityts) during ;his employment or work-assignment period.
IS Reporting of radionuclide intakesaas determined by sir sampling, is not required by 10 CFR 20408. However, should thia option be chosen, indicate the time-weighted concentrations of radioactive material (i.e.. MPCKhoursl to which the individual was exposed during the time periods indicated in Column 13.
Refer to the last paragraph of die instructions for Column 13 for the time inervals to be used. Complete Columns 13. 14. and 15 for each entry in Column la.
Item number 19 Any biassay results that cannot be reported as described above should be entered here.
Item number 20 If you wish to send a copy of this report to the terminating individual to satisfy the notification requirements of 10 CFR 19.13. check the "Yes box.
PRIVACY ACT STATEMENT
Ptruant to 5 U.S.C. 552a(eX3l. enacted into lab by section 3 of the Privacy Act of 1974 (Public Law 93-579. the following statement is furnished to individuals and persons who supply information to the Nuclear Regulatory Commission on NRC Form 439. This information is maintained in a system of records designated as NRC-27 and deacribed at 40
Federal Register 45344 (October 1. 19751.
I AUTHORITY. Sections 53. 63.63.81. 103. 104. 161(b). and 161oof dithe Atomic Energy Act of as amended (42 U.S.C. 2073. 2093. 2095. 2111. 2133. 2134.
2201(b). and 22011o0). The authority for soliciting the social security number is 10 CFR Part 20.
2. PRINCIPAL
PURPOSE
(S). The information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory responsibility to monitor and regulate the safety and health prtices of its licensees. The data permit meaningjid comparison of both current and log-temr ex- porure experience among types of licensees and among licensees within each type. Data on your exposure to radiation ae available to you upon request.
3. ROUTINE USES. The information may be used to provide data to other Federal and State agencies involved in monitoring and/or evaluat radiation exposure received by individuals employed as radiation workers on a permanent or temporary bass and exposure received by monitored visitors. The Wormatio may also be disclosed to an ap pirops Federal. State. or local agency in the event the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. k is voluntary that you furnish the requested information, including name, date of birth, and social security number. The social security number is used to assure that NRC has us accurate identifier not subject to the coincidence of similar names or birth date. among the large number of persmons on whom data is maintained. Please note, however. dutt the licemiee must file a termination report containing certain required information, such as social security number, for each individual whose employment or work assignment has terminated and for whom personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR *20.202 and 20.408 may subject the licensee to enforcement action under 10 CFR 20.601.
S. SYSTEM MANAGERLS3 AND ADDRESS: Director. Office of Nuclear Regulatory Research U.S. Nuclear Regulatory Commissiin Washington. DC 20555
NRC FORM U.S. NUCLEAR REGULATORY COMMISSION I. TOF REPORT
10 CMRp0.411 REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUMBERIS)
OCCUPATIONAL EXPOSURE
SEE THE ATTACHED INSTRUCTIONS.
PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA
2. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDIVIDUAL tMMt. mte hmdli est) AND ADDRESS boItorl S. NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE IO(tlnall t. SOCIAL SECURITY NUMBER DATE OF ONTH I DAY
I M7. I YEAR
I BIRTH
PART 11. EXTERNAL DOSE DATA
18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.
PERODS OF EXPOSURE
_ 9. DEEP 10 WHOLE BODY D ALWt )I I. EXTREMITY DOSE froml Of
3.PRoCsI dEXPoSUElE SHALLOW take,)
a. TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW tint PART Ill. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
_12. PERSONNEL MONITORING FOREXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.
16. BIOASSAY RESULTS 17. DOSE ESTIMATES tnml NUCUADE IS
FORO INTAKE
14.
IO.
13. PERIOCISI OF EXPOSURE b. ANNUAL c. ORGAN 4MPC.HrsI
Veretdpte A A.NULDE 16 FR a. IN VIVO InCiI b. URINALYSIS S. COM-
is. II RESULTS I LI MITTED DOSE
Ill BURDEN t21 ORGAN DOSE
19. OTHER BIOASSAY RESULTS
0. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF tO CR 19.13. CHECKTHE FOLLOWING BOX.
YES IThise m fian ted to VW rwlew povmion of VWeNdlRoar ltovy CGm ons regulaton 10 CFR Part 19. Yu. amaw waew,w mqhwt AN Athr rferme.)
INSTRUCTIONS FOR COMPLETING NRC FORM 439, Report of Terminating Individual s Occupational Exposure If you re licensed by the U.S. Nuclear Regulatoty Commission (NRC)ja specified in 520.408(a). 10 CFR Part 20. you are required to submit termination radiation exposure reports on certain individuals to the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regubatosy Commission. Washington. DC 20555. This infornation is to be taken from dose records that must be maintained under §20.401 for individuals likely to receive exposure to radiation that exceeds a certain percentage of dte NRC dose standards for the whole body, skin or extremities-25% for workers of age 18 years or moe. 5% for workers younger than IS. The term 'iadividual- is used below to represent the worker for whom this repor is submitted. The term "dose" as used in Form 439 and in these instructions refers to the dose in rems as defined in 20.41a) and subsequently designated "dose equivalent"
in ICRU Report 11(1968). The time to be covered by this report is that period of employment. or work assignment in your facility(s), which ended with the most recent ternnination aid was not interrupted by any previous tenmination during which personnel monitoring was required by 520.202t(a) anor biossays were required by your license. Termination" is defined in 120.3tXt19). Parts U and 11lof this form reflect regulatory requirements as well as requests intended to standardize reporting methods: requests are dearly identified as such.
PART I LICENSEE AND INDIVIDUAL IDENTIFICATION DATA
This pan identifies the licensee submitting the report and the termiouting individual It must be completed even if only one of the remaining Parts of this form is applicable. Enter the following data:
ITEM NUMBER
I Date that the report was prepared.
2 Current NRC license number assigned to the facility(s) in which the individual received the reported dose. If more than one license is involved, enter the license numnber for the facility or aivity under which most of the dose was iocurred as the first number. If this is att practical enter the license numbers in the order of original issuance.
3 Name and address of your facility as it appears on your NRC license.
4 The individual's first sme. middle initial, ind surname. (Address of the individual may be included. but it is not entered Into the NRC records system.)
5 The ime and ufiress of the individual's employer, if it is different from the reporting licensee. (Optical; nor entered into the NRC records system.)
6 The individual's social security number: If not available, enter the word "unkswon"
7 The individual's date of birth.
PART H. EXTERNAL DOSE DATA
For the purpose of this form. dte deep dose is defined as the dose asses at a tisue depth of 300 or 1.000 mg/cm' (or less). the shallow dose is definad as the dose to dheskin of any part of the body, rid the extremities are defined as hands and forearms. fet and nkles.
Item Number 8 If the Individual was not monitored for external exposure to radiation, you are s to check die box to the left mnd go to Part n1.
COLUMN NUMBER
9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your ficility(s) pursuant to 120.202. You are reque tod o e an- sual increments up to the year of termination and increments nooto eceed one quarter for the year in which the Individual terminated:
ANNUAL: Indiate de month aid year of the beginning date of exposure when showing annual Increments (e.g.. May 1979) and indicate the year only for bsequent increments.
QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by date;
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (mooth, day. year);
Enter the following data:
IEL Unless the eyes are shielded, enter the deep dose assessed at a tissue depth of 300 mgcm' (lens depth) or less. If dhe eyes are protected by shielding which has a tissue equivalent thicknes of 700 mg/cm' or more. the deep dose may be assessed at I000 mgkem' (gonad depth) or less. Enter the total dose of record. ie.. the highest dose received at the slected depth. from all types of external radiation sources, at any location on die body except the skin and the extremities (hands and forearms. feet mid ankles).
loc For all skin areas, except that of the extremities, enter in column l0c the shallow dose of record. Record dhe total dose to the kin. i e1' the highest dose delivered by all radiation incident on the skin. including non-trivial doses from Skin contamionaion, which penettes to the depth at which the shallow dose is determirne. The dose st a depth of 7 mgeimnor less, averaged over I cm'. is acceptasle. If Column Ilk is left blank. it will be assumed that the entry in l0t is applicable also hor the shallow dose. Therefore, an entry hor shallow dose is required only if it exceeds the deep dose.
lb & d You re equee to ener in column lOb the contribution made by neutron radiation to the dose reported in Column Ith, mndto enter in Column l0d the eontributiiinudeby beta radiation to the dose reported in Column lOc. Enter XXX if it is known that there was no exposure to radiation of the type specified in she column heading. Enter UNK if a detectable exposure is reported in Ith or lWc which could have included a beta or neutron contribution Of unknown magniude.
10 & 11 You re r bt enter mnor zao (in each colurnr of 10. or in II) if the dose was undetectable. ie.. the radiation to which the worker's dosimeter was exposed produc a response that you considered to be statistically indistinguishable from dheresponse esused by inherent varibilities o the dosmeter system. Note It is sometmcs required to add m (or its equivalent) to a real number; although NRC regulations do nut specify a summation procedure. the NRC staff arbitrarily assigns 10 mnrems to be a value of m (assuming 0.5 L C 10 C L where L is the detection limit) for the purposes of statistical analyses.
11 Reporting of the extresniry dose is required. You are m to comply in the following manner. Enter the dose of record. i e.. the highest dose.
averaged over any area of I cm'. determned for the rkiof the hMndsand foreans or feet tad ankles during the reported period. It is unnecessary to specify the extremity that received the dose: doses to different extremities should not be added together. The dose is to include that delivered by all radia- tion incident on the k. including nun-trivial doses from skin contamination. which penetrates to the depth at which the shallow dose is determined. The dose at a depth of 7 mgtcm' or less is acceptable. If Column II is left blank, it will be assumed that the entry in l0c is applicable also for hr extremity dose; a ensy in Column II is required only if the shallow dos exceeded the deep dose.
PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
If you are licensed by the NRC as specified In 520408(aj. 10 CFR Part 20. and if your license requires bioassay services for workers at your facWiy. you re required to submit ter- aiination MM on personnel exposures to radioactive material, containing information Is you have obtained in compliance with dhe license and recorded in compliance with
520.401. You we ted lo include in each termination report information that you have obtained in compliance with 520. C3(a)(3) and 20. 103(cX2) and recorded in compliance with 520.401. This part provides hor the reporting of internal monitoring procedures in terms of bioassay results, dose estimates, or itake. Any one (or more) of these reporting methods may be used. The term "individual" is used below to represent hie worker horwhom this report is submitted. The term "exposures to radioactive material" is used in con- nection with these temnaton reports to represent the entry of radioactive material into the body.
- tem Number 12 If the individual was ntomonitored for exposure to radioactive material, you aerequested to check dhe box to hr left; otherwise, enter the following dau:
Column Number 13 If bioassay results are repotned (Column 16). you mm ested to use the following format. Summarize by year. separately listing the nunber of measurements which indicated quantities or concenurationsVwere undetectable, ie'. in the detection system used, the ndionuclide present (if ny) pro- duced a response that you considered to be statistically indistinguishable from iu background. In Column 13 enter each year bioassay was performed. In- cluding dhe year of termination. In Columns 14 through 16. use two lines for each year. as In the exanple shown below. the upper line for detectable results and the lower line for those undetectable. In 16a and/or 16b: Iine enter dhe number (including zero) of detectable measurements followed in parenthesis by th highest verified result if ny lower line, enter thenumber Including zero) of measurements indicating undetectable amounts.
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)
COLUMN NUMBER
13 iContinuled Column 13 Column 14 Column IS Column 16
16aglI 16t421 16b (IpClL.
19J2 U-nat 1 0 lung 2(23
2 lung 10
1913 U-nat(Th 2343 ..I. 1t71 lung 4(61 I lung a
1984 U-natth 2343 ..I. 2tl41 lung 12133
0 lung 0
Units orrthe numbers in parentheses shown in Column 16b are to he specified in the heading for Column 16b. If Columns 17 or IS are completed. notr- tions in Column 16 are unnecessary.
If die done commitment t0Syear integrated dose) is reported. indicate in Column 13 by beginning and ending dates (month. day. yeast the period during which the associated radioactive material was taken into the body.
If atnal doses ar repoted. enter is Cohutn 13 the calendar year over which each dose was integrated. including the first and any succeeding years of this employmnent or work assignment and the year following the termination date.
For entries in Column IS tintakel. specify the reporting intervals tperiods of exposurel during which the individual was exposed to concentrations of radioactive material. using annual incremnts up to the year of termination and increments not to exceed one quarter for the year in which the individual terminated. The periods of exposure for intakes should appear as follows:
ANNUAL: Indicate doemonds and year of the beginning date of exposure when showing annual incremtents (e.g.. June 923) ;andindicate the year only for subsequent annual increments.
QUARTER: For each completed quarter of the yer of termination, indicate the quarter and year by date CURRENT QUARTER: Specify the beginning and ending dates of die actual exposure period (month day. year)
Reported intakes which include only the quantities required to be asses in accordance with £20.103(aX3) are acceptable.
14 Identify die symbol used in 10 CFR Part 20. Appendix B. for the radionuclide or mixture of radioucldide for which in vivo and/or urinalysir measurements were performed (e.g.. Co 60. U 2351. If the measured quantity of activity fcr one radionuclide is also used to estimate other radlonuclide quantities. identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in the directions for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined fromtmeasurements of Th
234 photons.
Is Enter the form. S for soluble or I for insoluble. of the radionuclide to which the worker was exposed. If unknown. use quotes around the letter. thus in- dicating which concentration value in Part 20. Appendix 3. Table 1. Column 1. assued to apply.
16. 17 & IS These columns allow for the reporting of the results of the internal monitoring procedures in terms of bioassay results, or dose estimates. or intake. You may use one or more of doesemethods.
Mall13 A a(2) For each year during which in vivo measurements were performed. as shown in Colunn 13. enter in Column 16*0ll the number of detectable measurements followed by the highest verified result (in nanocuriesi is parentheses. On the next line in this column, enter the number of neasuremen that indicated undetectable amounts. Specify in Column 16a42) the organ in which the indicated radionuclide war found. See die example given in the directions for Column 13.
26b First. enter the gravimetric or radiometric unit in which the urinalysis results are reported (e.g.. miicrograms per liter. nanlocuries per liter in the blank space of the heading for Column 26b. In Column 16b. for each year during which urinalyses were performed. enter the nruber of detectable resultsi followed by the highest numerical value of the concentration it urine of he radionuclide listed in Columis 14 for die yew specified in Column 13. On the next line in this column. enter the number of measurements indicating undetectable amounts. Seedie example given in die directions for Column 13.
17a. b. & c Specify in Column 17c the organ or tissue receiving doses estimated it Column 17a or 17b. (Note do it is not necessary to provide both the conmitted and annual doses.) For Columns 17. and 17b you are requested to follow die procedures below: if any alternative procedures are used. describe them on the back of this form. In 17a. enter the dose integrated from t to 50 years. where t is the beginning date shown in Column 13. In 17b enter the dose in- tegrated over each calendar year shown for this purpose in CoTuma 13. Include the ftrat and any succeeding yeatrs of this employment or work assignment and the year following the termination date. Base dose estimates on the quantity (ts a minimuml of the radionuclide. Column 14. taken into the body at your facilityis) during this employment or work-assignmema period.
IS Reporting of radionuclide intakes. as determined by air sampling. is not required by 10 CFR 20.40S. However. should this option be chosen. indicate the time-weighted concentrations of radioactive material (i.e.. MPC-hoursi to which the individual was exposed during the time periods indicated in Column 13.
Refer to dte last paragraph of the instructions for Column 13 for the time intervals to be used. Complete Columns 13. 14. and 15 for each entry in Column
12.
Item number 19 Any bioassay results that cannot be reported as described above should be entered here.
Iert number 20 If you wish to send a copy of this report to the terminating individual to satisfy the notification requirements of 10 CFR 19.13. check the "Yes" box.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552ate1433. enacted into law by section 3 of die Privacy Act of 1974 (Public Law 93-579i. the following statement is furnished to individuals and persons who supply information to the Nuclear Regulaney Commission an NRC Form 439. This information bi maintained in a sysem of records designated at NRC-27 and described at 40
Federal Register 45344 (October 1. 1975p.
1. AUTHORITY. Sections 53. 63. 65. 21. 103. 104. 161(bl. and 161(3 ofdthe Atomic Energy Act of 1954. ai amended 142 U.S.C. 2073. 2093. 2095. 2111. 2133. 2134.
2201tbl. and 22012(el. The authority for soliciting the social security number is 10 CFR Part 20.
2. PRINCIPAL
PURPOSE
ISI. The information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory responsibility to mtonisor and regulate the safety and health practices of its lkensees. The date permit a meaningpJ compnrison of both current and long-term ex- posure experience among types of licensees and among licensees within each type. Data on your exposure to radiation are available to you upon request.
3. ROUTINE USES. The information may be used to provide date to other Federal and State agencies involved in monitoring and/or evaluating radiation exposure received by individuals emplyed as radiation workers on a permanent or temporary basis and exposure received by monitored visitors. The information may al5o be disclosed to an ap- propriate Federal. State. or local agency in die event the inrissation indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntary that you furnish the requested information, including name. date of birsh. and social security number. The social security number is used to assire that NRC hasan accurate identifier not subject to the coincidence of similar names or birth date among the large nunber of persons on whom dat is maintained. Please nxte. however. that the licensee must file a termination report containing certain required information, such as social security number. for each individual whose employment or work assignment has terminated ild for whom personnel mndtoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR 120.202 and 20.408 may subject the licensee lo enforcement action under 10 CFR 20.601.
S. SYSTEM MANAGERtS) AND ADDRESS: Director. Office of Nuclear Regulatory Research U.S. Nuclear Regulatory Commission Washington. DC 2055
U.S. NUCLEAR REGULATORY COMMISSION . DATE OF REPORT
NRC FORM 439
4J51 -
10 CFR J20.t0
2.NRC LICENSE NUTABERIS
REPORT OF TERMINATING INDIVIDUAL'S
OCCUPATIONAL EXPOSURE
SEE THE ATTACHED INSTRUCTIONS.
PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATA
4. NAME OF INDMDUAL mit.mWlde t. Ilal AND ADDRESS kptta
3. NAME AND ADDRESS OFREPORTING UCENSEE
5S NAME AND ADDRESS OFEMPLOYER. IF DIFFERENT FROM ABOVE tOotbirfg l. SOCIAL SECURITY NUMBER l7. ATE OF I MONtH I DAY I YEAR
I BIRTH
PART II. EXTERNAL DOSE DATA
IS PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.
10 WHOLE BODY OOSF ImP A 11. EXTREMITY DOSE (mu)
DEE PSHLLWE ki S. PERIODtSI OF EXFOSURE
b. NEUTRON c. TOTAL d. BETA SHALLOW ftahIF
r doe rwt . TOTAL
PART Il. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
PROVIDED.
12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT
I6. BIOASSAY RESULTS 17. DOSE ESTIMATES (umm)u b. URINALYSIS L S. COM A C. ORGAN I KSTE
13. PERt)OISI OFEXPOSURE 14. NUCLIOE tS 11 VNO InCil
13. 14. NUCLIDE IS ORMAN.UINLVIVO IANlIMPC-Hrs.1 RESULTS I Li MITTED, DOSE
trts tewil(S. II
(Il BURDEN 121ORGAN DOSE
19. OTHER BIOASSAY RESULTS
19.13. CHECK THE FOLLOWING BOX.
2X. IFTHIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REQUIREMENTS OF 10 CFR
DpnOvi e of the Maclw ReguLatory Coalason's rgulcian I0CFR Prt19. Vouf *tprsww Iw for ilar b feb .I
I YESrTo won lsaporrnsd to wNdt
INSTRUCTIONS FOR COMPLETING NRC FORM 439, Report of Terminating Individua's Occupational Exposure If you are licensed by the U.S. Nuclear Regulatory Commission INRC) as specified in 120.40(a). 10 CFR Part 20. you are required to submit termination radiation exposure reports on certain individuals so the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is lo be taken from dose records ltht must be maintained under 120.401 for individuals likely to receive exposure soradiation that exceeds a certain percentage of the NRC dose standards for die whole body, skin or extremitiea-25% for workera of age 18 years or more. 5% for workers younger thn IS. The term bidividual' is used below to represent die worker for wbom dis report is submitted. The term doseeasused in Form 439 and in these instructions refers to the dose in rems as defined in §20.44al nd subsequently designated "dose equivalent"
in ICRU Report U t1964). The time to be covered by this report is dis period of employment. or work assignment in your facility(s). which ended with the most recent termination and was ot Interrupted by any previous termination during which personnel monitoring was required by 520.202(a) and/or bionssays were required by your license. 'Termination" is defined in 120.3(a)X19). Phts H and HI of this form reflect regulatory requirements as well as requests intended to standardize reporting methods: requcsts are clearly identified as such.
PART 1. LCENSEE AND INDIVIDUAL IDENTIFICATION DATA
This part identifies the licensee submitting the report and the terminating individual. It must be completed even if only one of the remaining Parts of Ihis form is applicable. Enter the following data:
ITEM NUMBER
I Date that the report was prepared.
2 Current NRC license number assigned to the facility(s) in which the individual received the repored dose. If more than one license is involved, enter the license number for the facility or activity under which most of the dose was incurred as the first number. If this is not practical, enter the license numbers in the order of original irsuance.
3 Name and address of your facility as it appears on your NRC license.
4 The individual's first name, middle initial, and surname. (Address of the individual may be included. but it is sot entered into die NRC records system.)
5 The name and address of die uindividual's employer. if it is different from the reporting licensee. (Optional: not entered into the NRC records system.)
6 The individual's social security number. if not available, enter the word '"unknown."
7 The individual's date of birth.
PART U. EXTERNAL DOSE DATA
For the purpose of this form, die deep dose is defined as the dose assessed at a tissue depth of 300 or 1.000 mg/em' (or less). the shallow dose is defined as the dose to the skin of any part of the body. and the extremities are defined as hands and forearms. feet and ankles.
Item Number S If the individual was not monitored for external exposure to radiation. you are reque ted to check die box so the left and go to Part i.
COLUMN NUMBER
9 Specify the reporting intervals (periods of exposure) that sheindividual was monitored at your facility(s) pursuant to 20.202. You are requested to se an- sual increments up to the year of oermination nd increments not to exceed one quarter for the year in which the individual terminated:
ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e.g.. May 1979) and indicate the year only for subsequent annual increments:
QUARTER: For each coapleted quarter of the year of termination. indicate the quarter and year by date.
CURRENT QUARTER: Specify the beginbing and ending dates of the actual exposure period (mooth, day. year).
Enter die following data:
la Unless the eyes are shildded, enter the deep dose assessed at a tissue depth of 300 mgt/cm lens depth) or less. If the eyes are protected by shielding which has a tissue equivalent thickness of 700 mg/cm' or more. die deep dose may be assessed at 1000 mg/cm' (gonad depth) or less. Enter the total dose of record. i.e.. shehighest dose received at the selected depth, from all types of external radiation sources, at any location on die body except die skin and the extremities (hands and forearms, feet and ankles).
lOc For all akin areas except that of the extremities, enter in column 10c the shalow dose of record. Record the ta dose so the akin. i.e.. she highest dose delivered by all radiation incident on bhe skin, including non-trivial doses from2 skin contamination. which penetrates to die depth at which the shallow dose is determined. The dose at a depth of 7 mg/cm' or less, averaged over I cm . is acceptable. If Column ICc is left blank. it will be assumed that the entry in 1bi is applicable also for the shallow dose. Therefore. an entry for shallow dose is required only if it exceeds the deep dose.
l0b & d You re requested to enter in column l0b the contribution nmde by neutron radiation sothe dose reported in Column 10. and so enter in Column l0d the contribution made by beta radiation lo the dose reported in Column lOc. Enter XXX if it is known that there was no exposure lo radiation of the type specified in the column heading. Enter UNK if a detectable exposure is reported in IQc or lOc which could have included a beta or neutron contribution of unknown mignitude.
10 & 11 You we r ested to enter mnor zero (in each column of 10. or in II) if the dose was undetectable. i.e., the radiation to which the worker's dosimeter was exposed Md* response thlt you considered to be statistically indistinguishable from the response caused by inherent variabilities of the dosimeter system. Note: It is sometimes required to add D (or its equivalent) to a real umber; although NRC regulations do not specify a Summation procedure, the NRC staff arbitrarily assigns 10 mrems to be a value of m (assuming 0.5 L ( 10 4 L where L is the detection limit) for the purposes of statisti analyses.
II Reporting of the extremity dose is required. You are qsto comply in the following manner. Enter the dose of tecord. I.e... the highest dose.
averaged over any area of I cm'. determined for the W ofahe hands and forearms or feet nd ankles during the reported period. h is unnecessary to specify the extremity that received the dose; doses to different extremities should rot be added together. The dose is to include tht delivered by all radia- tion incident on the skin, including non-trivial doses from skin contamination. which penetrates to the depth at which dic shallow dose is determined. The dose at a depth of 7 mg/cm' or less is acceptable. If Column II is left blank. it will be assumed that the entry In I0c is applicable also for the extremity dose. an entry in Column II is required only if the shallow dose exceeded the deep dose.
PART m. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
If you are licensed by the NRC as specified bi 120.408(a). 10 CFR Part 20. and if your license requires bioassay services for workers at your facility. you are required to tubmit ter- mintation reports on personnel exposures to radioactive material. containing information that you have obtained in compliance with the license and recorded in compliance with
520.401. You are to Include in each termnation report informaution that you have obtained in compliance with pO. 103(aX3) and 20. 103(c)(2) acd recorded in compliance with 120.401. This part provides for the reporting of internal monitoring procedures in errms of bioassay results. dose estimates. or Intake. Any one (or more) of these reporting methods may be used. The erm bidividurd' isused bWeow to represent the worker for whom this report is submitted. The erm "exposures to radioactive materia is used in con- section with these termination reports to represent the entry of radioactive material into the body.
Itan Number 12 If the individual was not monitored for exposure to radioactive material. you are qused to check the box to the left: otherwise, enter the following data:
Column Number 13 If biosay results a repored (Column 16). you ar nested to ne die following format. Summarize by year. separately listing the number of measurements which indicated quantities or concentratiEosd were undetectable. I.e.. in the detection system used. the radionuclide present (if any) pro- duced a response that you considered to be statistically indistinguishable from its background. In Column 13 enter each year bioassay was perforted, in- eluding the year of termination. In Columns 14 through 16. use two lines for each year. as in the example shown below. the upper line for detectable reults and tie lower line for those undetectable. In 16a and/or 16b: uper I enter die number (including of detectable measurements followed in Iaol ime ber (including zero) of meaurements iidiatisg undetectble mounts.
parenthesis by the highest verified result, if any: lowea line. enter thd
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)
COLUMN NUMBER
13 WContinucedl Column 13 Column 14 Column 15S Column 16 I6dall 162) Itb (pCi/LI
19S2 U-nm "I" 0 lung 2l
2 tuns 10
19S3 U-nauTh 234) 2If7i luns 4(6)
I lung 8
19S4 U-nst(Th 234) 1 204I tuns 12(13
0 lung 0
Units for the numbers in parentheses shows in Column Itb are to be specified in the heading for Column Itb. It Column 17 or 11 are completed. notr- tions in Column 16 are unnecessary.
If the dose commitment 450-year integrated dose) is reported. indicate in Column 13 by beginning and ending dates imonth. day. year) the period during which the associated radiactive material was taket into the body.
If arnnual does are repoted. enter in Column 13 the calendar year over which each dose was integrated. including die frt and usny succeeding yeas of this employment or work assignment and the year folowing die termination date.
For entries in Column IS fintakei. specify the reporting intervals (periods of exposure) during which tke individual was exposed to concentrations of radioactive naterial. using annual increments up to the year of termination and increments not to exceed one quarner for tde year in which the individual terminated. The periods of exposure for intakes should appear as follows:
ANNUAL: Indicate tie month and year of the beginning date of exposure when showing arnnul increnents lte.. June 19S31and indicate the yew only for subsequent nnuat increments.
QUARTER: For each completed quarter of tde year of termination. indicate the quarter and year by date.
CURRENT QUARTER: Specify tde beginning and ending dates of die actual exposure period (month. day. year).
Reported intakes which include only tde quantitie required to be assessed in accordance with PM 103(a13) rte aeptable.
14 Identify the symbol used in 10 CFR Pan 20. Appendix B. for the radionuclide or mixture of radionuclides for which in vivo and/or urinalysis measurements were performed (e.g.. Co 6D. U 235). If the measured quantity of activity for one radlonuclide is also used to estimate other radionuclide quantities, identify the radionuclide actually measurcd in parentheses immediately after die radionmclide listed in Column 14. Seethe example given ini te directions for Column 13 where U-nat(Th 234) is entered in Column 14 indicating that the uranium lung burdes was determined from measurements ofTh
234 photons.
Is Enter the form. S for soluble or I for insoluble. of the radionuclide to which the worker was exposed. If unknown. use quots aroundthe letter. thus is- dicating which concentration value in Pan 20. Appendix B. Table 1. Column 1. was assumed to apply.
16. 17 & II These columns allow for the reporting of the results of die internal monitoring procedures in terms of bioasy results. or dose estimates. or intake. You may use one or more of these methods.
16Mal)A l2b For each year during which in vivo measurements were performed, as show in Column 13. enter in Column lonl ) die number of detectable measurement followed by the highest verified result (is manocuriesl in parheses. Os tde next linte it ths column. enter tde nunber ofdnmaur s that indicated undetectable amounts. Specify in Column 16a12)the organ in which the indicated radionuclide was found. See the example gives is the directions for Column 13.
Iob First, enter the gravimetric or radiometric unit in which tde urinalysis results ar repoed (e.g.. micrograms per liter. naznocuries per liter) in the blank space of the heading for Column l6b. Is Column lob. for each year during which urinslyses were performed, enter the number of detecutble rsult followed by the highest numerical value of the concentration in urine of the radionuclide listed in Column 14 for the year specified in Column 13. On tde neXt line in this column. enter the number of measurements indicating undetectable amounts. See the example given in tde directions for Column 13.
17a. b. A c Specify in Column 17c tde organ or tissue receiving doses estimated in Column l7h or 17b. (NotWthat it is not necessary to provide both the committed and annual doses.) For Columns 17aand l7b you are requested to follow the procedures below: if any alternative procedures are used, describe thie on the back of this foe.. In 17. enter the dose integrated from t to 50 years. where t is the beginning dam showl in Column 13. In l7b enter tde dose in- tegrated over each calendar year shown for this purpose in CdTumn 13. Include tde frst and any succeeding years of this employment or work assignment and the year following the termination date. Base dose estimates on the quantity (s a minitum) of the radionuclide. Column 14. takes into the body at your facility(s) during this employment or work-assignnient period.
IS Reporting of radionuclide intakes, as determined by sir sampling. is not required by 10 CFR 20.408. However. should this option be chosen. indicate the time-weighted concentrations of radioactive material (i.e.. MPC-houns to which the individual was exposed during the time periods indicated is Column 13.
Refer to the last paragraph of the inst uctions for Column 13 for the time intervals tn be used. Complete Colunuis 13. 14. and 15 for each entry in Column
18.
Item number 19 Any bioassay results that cannot be reported as described above should be entered here.
Item number 20 If you wish to send a copy of this report to the terminating individual to satisfy the notification rquirements of 10 CFR 19.13. check tde "Yes" box.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552aieNt3. enacted into law by section 3 of the Privacy Act of 1974 tPublic Law 93-579T.the following statement is furnished to individuals and persons who supply information to tbe Nuclear Regulatory Commissioa on NRC Form 439. This information is maintained in a system of records designated as NRC-27 and described at 40
.Federal Register 45344 (October 1. 1975.
I. AUTHORITY. Section 53. 63. 65. 51. 103. 104. 161(b). and 161tol of die Atomic Energy Act or 1954. as amended (42 U.S.C. 2073. 2093. 2095. 2111. 2133. 2134.
2201(b). and 2201tol). The suthority for soliciting the social security number is 10 CFR Pan 20.
2. PRINCIPAL
PURPOSE
(SI. The information is used by the NRC in its evaluation of the risk of radiatiot exposure associated wit the licensed activity and in exercising its statuiory responsibility to monitor and regulate the safety and health practices of its licensees. The dart permit a meaninghJ comparison of both curnt and long-tenn ex- posure experience among type. of licensees and atong licensees within each type. Data on your exposure to radiation are available to you upon reest.
3. ROUTINE USES. The information may be used to provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation exposure received by individuals employed as radiation workers on a permanent or temporary bais and exposure received by monitored visitons. The inormatio may sIs be disclosed to sn -
propriate Federal. State. or local agenty is the event the infonnato indicates a violation or potential violation of law and in the course of ast dministraive or judicial proceeding.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMAT1ION ON INDIVIDUAL OR PERSON. It is voluntaq that you hrnmish the requested informration. including nanie. date of birth. and social security number. The social security nunber is used to assure dathNRC has an accurate identifier not subject to the coincidence of similar names ur birth dues among the large number of petiom on whom damtis maintained. Please note. however. that the licensee must file a termination repont containing certain required information, such a social security number. for ecdh individual whose employment or work assignment hab terminated and for whom personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR §20.202 and 20.408 may subject the licensee to enforcement action under 10 CrR 20.601.
5. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nucear Regulatory Research U.S. Nuclear Regulatory Cirnmissiam.
Washington. DC 20555
1. DATE OF REPORT
US. NUCLEAR REGULATORY COMMISSION
NRC fORM 4S
14U1 UBRS
IS CFRJ2.01S
REPORT OF TERMINATING INDIVIDUALS NRC UCENSE NUMBERISI
OCCUPATIONAL EXPOSURE
SEETHE ATTACHED INSTRUCTIONSO
DATA
PART I. LICENSEE AND INDIVIDUAL IDENTIFICATION
4. NAME OF INDMDUAL (firs. ni6_ u. ls*imAND ADDRESS hp0osfa)
3. NAME AND ADDRESS OF REPORTING LICENSEE
ABOVE IoptDND
5. NAME AND ADDRESS OF EMiPOYER. IF DIFFERENT FROM
OATE Of I M7 MONTH I DAY I YEAR
6. SOCIAL SECURITY NUMBER
BIRTH
PART II. EXTERNAL DOSE DATA
TO RADIATION WAS NOT PROVIDED.
S. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE 1 I1 EXTREMITY DOSE #mm la wimmf BODY WF 1{
DEEP 0kng O SHALLOW
9. PERIODISI OF EXPOSURE C. TOTAL d. BETA SHALLOW (skn)
a. TOTAL b. NEUTRON
-t dom HIl.INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
PART
11.PERSONNEL MONITORINGFOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED. ImmI1.ITK
17. DOSE ESTIMATES
IS. BIOASSAY RESULTS
a. COM. b.ANNUAL c. ORGAN IMKCNrsIl
15. FORM m.IN VIVO InCil b. URINALYSIS DOSE
1.EROSIOEXOUE 14. NUCLIDE RIESULTSI LI MITTED
1ktdieht Is, II DOSE
It) BURDEN 121ORGAN
19. OTHER BIOASSAY RESULTS-
BOX.
REa IREMENTS OF 10 CFA 19.13. CHECKTHE FOLLOWING
D. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION
MoguIMorICwmsn8ws mpbtoon 10 CFR Part 19.You WhosL ewve On mpowt tho he ference. I
VW1 NuCkM
YES Tho ,pwf is AmWud to aouwider h provwioOfl
ar - 4 INSTRUCTIONS FOR COMPLETING NRC FORM 439, Report of Terminating Individual's Occupational Exposure tosubmit senrtnination radiation exposure reports If you are licensed by the U.S. Nuclear Regulatory Commission (NRC) as specified In 120.408(a). 10 CFR Part 20. you arerequired 20555.This information isto be bken from so die Director. Office o Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC
oncertain individuals a certain percentageof theNRC dose standards for diewhole dose records that must be maintainedunder 520.401 for individuals likely to receive exposure to radiation dtt exceed body. tinor extremities-25% for workers of age ISyears or more.5% for workers younger thn IS.The tem individual" is used below torepresent dieworker for whom this report issubmitted. The tern"dose" as used inForn 439 tmd in these instructions eferstto the dose in remt as defined in 520.4ta) and subsequendy designated "dose equivalent"
with de mostrecent termination in ICRUReport 11 (1968). The time to be covered by this report is that period of employment or work assignment in your facility(s). which ended bioassays were required by your license. "Termination" is and was not Interupted by any previous termination during which personnel monitoring was required by 120.202(a and/or reporting methods:requests ar clearly identified as defined in 520.3(X 19). Parts II and I1 of this form reflect regulatory requirements as well es requests intended tostahdtrdize such.
PART 1. LICENSEE AND INDIVIDUAL IDENTIFICAllON DATA
This part identifies the licensee submitting he repot and the terminating individual. It must be completed even if only one of the remaining Parts of this form is applicable. Enter the following data:
ITEM NUMBER
IDte that thereport was prepared.
Current NRC license number assigned to the facility(s) inwhich the individual received di reported dose.If Ifmore than onelicense is involved, enter the
2 as he first number. ths is otpractical. enter the license numbers licenenumber for the fcility or activity under which most of the dose was incurred in die order of original isuance.
3 Name ndaddress of your facility as it appears on your NRC license.
4 Theindividual's first name.-middle initial. and surname. (Address of the individuadIny be included, buthist enatered intodie NRCrcords yn.
into the NRC records system.)
5 The me and atddress of the Individual's employer. if itis different from the reporting licensee. (Optional; otentered
6 The Individual's social security number; If not available. enter the word "unknown."
7 The Individual's date of birth.
PART U. EXTERNAL DOSE DATA
dose is defined as the dose to the skin of For the purpe of this form, the deep dose is defined as the dose assessed at a tissu depth of 300 or 1,000 mg/cm' (or less). the shallow any past of the body. nidtheextremities are defined as hands and forearms. feet and akles.
go to Part II1.
item Number S If the individual was notmonitored for external exposure toradiation. you are fequasux tocheck the box to theleft nod
!COLUMN NUMBER
to520.202 You amre touse s- t sq
9 Specifythe reporting intervals (periods of exposure) that the individual was monitored at your facility(s) pursuant tbe individual terminated:
nualincrements us tothe year of termination midIncrements notso exd e quarter for theyear in which Indicate the year only for (e.g.,May 1979) and ANNUAL: Indicate the sontdi and year of the beginning date of exposure when showing annual increments ubset annual increments;
QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by date CURRENT QUARTER: Specify thebeginning and ending dates ofdie atual exposure period (month, day.
year).
Enter the following data:
less. If tbeeyes are prc by shielding which IO& Unless the eyes are shielded. enter the deep dose assessed at a tissue depth of 300 mg/cm' (lens depth) or (gonad depth) or less. Enter thetotal dose or has a tissue equivalent thickness of 700 mgl/n' or mere. thedeep dose may be assessed at 1000 mng/cm any location on the body except the akin arnd the record. Le.. the highest dose received at the selected depth. from all types ofextemal radiation saurces. at extremities (hads t forearms. feet and ankles).
die ttna dose to the a I.Le..the highest dose lOc For all akin aeas, except that of the extremities, nter in column lOc the shallow dose Of record. tboed which the shallow dose delivered by al radiation incident on the skin, Including non-trivial doses from akin contamination. which penetrates to die depth at Is determinied. Tbe dose at a depth of 7 mngtan' or less, averaged over I cma. is acceptable. If Column l0cisleft blank. itwill be assumed that the entry the deep dose.
in lOais applicable also for die shallow dose. Therefore. an entry for shallow dose is required only if It exceeds in Column lOs. atd so enter in Column l(o the l~b h d You art tquested to enter in column l0b the contribution made by neutron radiation so the dose teportedthere was so exposure toradiation of the type ontributhimiiaby beta radiation to the dose reported In Column lOc. Enter XXX if itIs known that have included a betaor neutron contribution of specified in the column heading. Enter UNKIf a detectale exposure Is reported in lOa or lOcwhich could unknown magnhide.
the worker's dosimeter was
10 h 11 You re t ostenter m or zero (in ech column of 10. or in II) If the dose was undetectable. i.e.. te radiation to which d ed sa rponse that yeu considered tobe tistlly din shble from the esponsem used by herent wriabilia of the dser e d xpw system. Note: Its sometimes required to add es (or its equivalent) to a real turmber; although NRC regulations do sot specify a sunuation procedure, die limit) for die purposes of Statistical NRC staff arbitrarily assigns 10 mrens to be a value of m (assuming 0.5 L 10 ( L where L is die detection analyses.
Enter the dose of ecord. i.e.. the highest dose.
Reporting of die extremity dose is required. You are requested to comply In the following manner.
averaged over any rea of I am'. determined for the i7 e bands and forearms or feet and ankles during the reported period. It Is unnecessary to dose is so Include that delivered by al radsa- specify dte extremity that received tbedose. doses to different extreities should net be added together. The The don Incident on the skin. including non-trivial doses from skin cnawmination, which penetntes to the depth at which the shallow dose Is determined.
5 in lOc isapplicable also for the extremity dose at a depth of 7 mg/cm or less is acceptable. If Column II Is let blank. it will be assumed that the entry dose; tm entry in Column I is required only If the shallow dose exceeded the deep dose.
PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL
services for workers at your faclity. you are required to submit ter- If you armlicensed by the NRC as specified in p0.406(a). 10 CFR Pat 20. and if your license requires bioassay with the license and aecorded in compliance with mination report on personnel exposures to radioactive material. containing Information that you have obtained in compliance with 120.103(aX3) and 20.103(cX2) and recorded in compliance
520.401. You wre quested ID cude in each terminstionrteport information that you have obtained in eompliance dose estimates. or hisake. Any one (or more) of these reporting with 120.401. This part provides for the reporting of internal monitoring procedures in terms of biotassay results. material" is used in cen- methods may be used. The term WIndividual" is used below to represent die worker for whom this report Is submitted. The term "'exposures to radioactive section with these termination reports to represent the entry of radioactive material Into the body.
If the individual wass t monitored for exposure to radioactive material, yOu atre u to check the box to the left: otherwise. enter the following data:
Item Number 12 Column Number 13 If bioassay results re reported (Column 16). you are uested to mse die following format. Summarize by year. separately listing the number of measurements which Indicated quantities or eoncentro that 1Wcre tectable ie.. n the detction stem used. the radionudide present (if any) pro-
13 enter eac year bioassay was perfoermed, in- duced a response that you considered to be statistically indistinguislhable from its background. In Column year of termination, In Columns 14 through 16. use two lines for each year. as in the example shown below. the upper line for dotectable eluding the the lower Line for those undetectable. In Ida and/or 16b: u li nter the number (including zero) of detectable measurements followed bi reults and parenthesis by the highest verified result. if any; lower line. enter thme (including zero) of measurements indicatdng sndetectable amounts.
C I
YNSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)
COLUMN NUMBER
13 (Continued; Column 13 Column 14 Column 13 Column 16 l6all) 16f21 l6b (pCUL
1932 U-nat 1 0 lung VI)
1983 U-natth 2341 2 lung 1o I 1..7 lung 4(61
1934 U-nat(Th 2341 Ilung S
1 2(14 lung 12(13)
0 lung 0
Units for die numbers in parentheses shown in Column 16b are to be specified in the heading for Column 16b. If Columns 17 or tions in Column 16 are unnecessary. IS are conmplted. nota- If the dose commitment 150-year integrated dose) is reported. indicate which tde associated radioactive material was taken into te body. in Column 13 by beginning and ending dares (month. day. year)
td period during If annual doses are reported. enter in Column 13 tde calendar year this employment or work assignmernt and the year following the termination over which each dose was integrated. including the first and any succeeding yearn of date.
For entries in Column 18 (intake;. specify the reporting intervals (periods of exposure) during which die individual was exposed to radioactive material. using annual increments up to the year of concentrations of termination and increments not to exceed.one quarter for the year terminated. The periods of exposure for intake& should appear as in which die individual follows:
ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e.g.. June 1983) and subsequent annual increments. indicate tie year only for QUARTER: For each completed quazier of the year of termination.
indicate the quarter and year by date.
CURRENT QUARTER: Specify the beginning and ending dates of the actual exposure period (month. day. year).
Reported intakes which include only the quantities required to be assesised in accordance with 120.103(a13; are acceptable.
14 Identify the symbol used in 10 CFR Part 20. Appendia J. for the radionuclide or mixture of radionuclides for which in vivo and'or measurements were performed (e.g.. Co 60. U 235;. If the measured urinalysis quantity of activity for one radionudida is alao used to essimate quantities identify the radionuclide actually measured in parentheses other radionuclidt directions for Column 13 where U-nat(Th 234; is entered in Column immediately after the radionuclide listed in Column 14. See die example gives ia the
14 indicating that the uranium lung burden was determined from
234 photons. measurements of Tl is Enter the form. S for soluble or I for insoluble. of the radionuclide dicating which concentration value in Part 20. Appendix B. Table to which tie worker was exposed. if unknown. use quoes around the letter. thus in-
1. Column 1. was assumed to apply.
16. 17 & 18 These coluinns allow for the reporting of the results of the internal monitoring pntcedunr in tems d bitty tts. or dose e may use one or more of these methods. or ie. You
16sil; a &12) For each year during which in vivo measurements were perforned.
as shown in Column 13. enter in Column l6rasI( the number of detectable measurements followed by the highest verified result (in nanocuries;
indicated undetectable amounts. Specify in Column 16c(21 the organ In parentheses. On the next line is this column. enter the number of meatiremenUs that in which the indicated radionuclide was found. See the example for Column 13. given in dte direction.
16b Firm enter the grnvimetric or radionetrik unit in which the urinalysis results are reported (eg.. micrograms per liter. nanocuries per Iter)
space of the heading for Column 16b. In Column 16b. for each is the blank year during which urinalyses were performed, enter the numiber followed by the highest numerical value of the concentration in of urine of the radionuclide listed in Column 14 for the year specified detectable results next line in this column. enser the number of measurements indicating in Column 13. On tde undetectable amounts. See the example given in the directions for Column 13.
l7s. b. & c Specify in Column 17e the organ or tissue receiving doses estimated and annual doses.; For Columns 17a and 17b you amrrequested in Column 17a or 17b. (Note thdt it is not necessary to provide to follow the procedures below: if any alternative procedures ae both the committed the back of this forta. In 17a. enter the dose integrated from t to used. describe themn ons
50 years. where t is the beginning dame shown in Colsuan 13. tn 17b enter the dose in- tegrated over each calendar year shown for this purpose in CdTumn
13. Include the Art and any succeeding yewn of this employment and the yer following the termination date. Base dose estimates or work assignment on the quantity fa a minimum; of the radionuclide, Column 14.
your facility(sl during this employment or work-assignment period. taken into the body at IS Reporting of radionuclide intakes. as determined by air sampling.
is not time-weighted concentrations of radioactive material (i.e.. MPC-hoursn required by 10 CFR 20.401. However. should this option be chosea indicate the to which the individual was exposed during the time perioda indicated Refer to te last paragraph of the instructions for Column 13 for the time intervals to be used. Complete Columns 13. 14. and 15 in Column 13.
for each entry in Column Item numter 19 Any bioray results that cannot be reported as described above should be entered here.
Item number 20 If you wish to send a o* of this report to the terminating individual to satisfy the notification requirements of 10 CFR 19.13. check the "Yes" box.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552aleH3t. enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93-579o. the following statement is fhished supply informatio sothe Nuclear Regulatory Commission on NRC to individuals and personn who Form 439. This information Lsmaintained in a system of records Federal Register 45344 (October 1. 1975). designated as NRC-27 and described at 40
1. AUTHORITY. Sections 53. 63. 65. 11. 103. 104. 161(b;. and
161(ol of the Atomic Energy Act of 1954. as amended 442 U.S.C.
2201fb;. and 22014o);. The authority for soliciting the social security 2073. 2093. 2095. 2111. 2133. 2134.
number is 10 CFR Parn20.
2. PRINCIPAL
PURPOSE
(S). The information is used by the NRC in statutory responsibility to monitor and regulate the safety and health its evaluatipn of the risk of radiation exposure associatedwibh the licensed activity and in exercising its practices of its licensees. The dat permit a metninghi comprison posure experience among types of licenees andamong licensees within each type. Data on your exposure to radiation ar avaible of both current and long-tern ex- to you upot request t
3. ROUTINE USES. The information mny be used lo provide data to other Federal and State agencies involved in monitoring individuals employed as radiation workers on a penranent or temporary and/or evaluating radiation expoture received by propriae Federal. State. or local agency in te event the information basis and exposure received by monitored visitors. The information indicates a violation or potential violation of law and in the course may alto be disclosed to an ap- proceeding. of an adinini v or judicial
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY
AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL
that you furnish the requested infornation. including name. date OR PERSON. It is voluntary of identifier not subject to the coincidence or similar names or birth birth. and social security number. The social security number is used to assure that NRC has an accurate dates among the large number of persons on whom data is maintaied.
licensee rmost file termination report containing certain required Please note. however. that the information. such as social security number. for each individual whose terminated and for whom personnel monitoring was required under employment or work assignment ha
10 CFR 20.202. Failure of the licensee to provide the information subject the licensee to enforcement action under 10 CFR 20Q601. under 10 CFR l20.202 and 20.408 may
5. SYSTEM MANAGER(S) AND ADDRESS: Director. Offi e of Nuclear Regulatory Research U.S. Nuclear Regulatory Commissitn Washingt. DC 20555
j LIST OF RECENTLY ISSUED GENERIC LETTERS
GENERIC
LETTER NO. SUBJECT DATE
84-20 Scheduling Guidance for Licensee Submittals of Reloads that Involve Unreviewed Safety Questions 8/20/84
84-21 Long Term Low Power Operation in PWR's 10/16/84
84-22 Not used
84-23 Reactor Vessel Water Level Instrumentation in BWRs 10/26/84
84-24 Clarification of Compliance to 10 CFR 50.49 Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants 12/27/84
85-01 Fire Protection Policy Steering Committee Report 1/9/85
85-02 Staff Recommended Actions Stemming From NRC
Integrated Program for the Resolution of Unresolved Safety Issues Regarding Steam Generator Tube Integrity 4/15/85
85-03 Clarification of Equivalent Control Capacity 1/28/85 For Standby Liquid Control Systems
85-04 Operator Licensing Examinations 1/29/85
85-05 Inadvertent Boron Dilution Events 1/31/85
85-06 Quality Assurance Guidance for ATWS
Equipment that is not Safety-Related 4/16/85
85-07 Implementation of Integrated Schedules 5/02/85 for Plant Modifications
85-08 10 CFR 20.408 Termination Reports - Format 5/23/85
85-09 Technical Specifications for Generic Letter 83-28, Item 4.3 5/23/85
85-10 Technical Specifications for Generic Letter 83-28, Items 4.3 and 4.4 5/23/85