NRC Generic Letter 1985-08: Difference between revisions

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{{#Wiki_filter:TO ALL HOLDERS OF CONSTRUCTION PERMITS AND OPERATING LICENSES
{{#Wiki_filter:TO ALL HOLDERS OF CONSTRUCTION PERMITS AND OPERATING LICENSESSUBJECT: 10 CFR 20.408 TERMINATION REPORTS -FORMATGENERIC LETTER NO. 85-08Pursuant to 10 CFR 20.408, licensees are required to submit to the NRC areport of each individual's exposure to radiation and radioactive materialwhen the individual terminates employment or work assignment at theirfacility. These exposure reports are commonly referred to as §20.408termination reports.Previously, we have not specified a preferred reporting format for compliancewith this regulation. However, the NRC is currently receiving approximately100,000 termination reports each year, and this number is steadily increasing.For purposes of efficient automatic data processing, it is important to use astandard format. Processing in a more timely fashion will make the data moreuseful to the NRC and others in their performance of various duties (seeEnclosure 1).For future §20.408 termination reports we request that you voluntarily use theattached Standard NRC Form-439. Instructions for completing the form are attachedto the form. Questions regarding these instructions should be directed to BarbaraG. Brooks, Office of Nuclear Regulatory Research, Washington, D. C. 20555,(301) 427-4577.The NRC is also conducting a pilot program for the electronic transmissionof the termination data to the NRC via computer tapes or by direct linkup tothe NRC's computing facility, and we would like to encourage you to considerparticipating. Should you desire more information about this program pleasecontact Ms. Brooks.The form is intended for use in connection with the information collectionrequirement established in Section 20.408, 10 CFR Part 20 and approved underOMB Clearance Number 3150-0014.ompson, JN*, Dir oro viion of Licensfng /g1/O ce of Nuclear Reactot egulationEnclosure:1.Ues-of Radiation Exposure Data I2. Five copies of NRC Form 439c i L ttflenercilel;1ers -g>8505210106PDQI A-DOCK O 500L
Uses of Radiation Exposure DataA number of NRC licensees have inquired as to how occupational-radiationexposure data (from reports required by the NRC)'are used by the NRC staff.This is a very appropriate inquiry that may be of importance' to many affectedlicensees. In combination with other sources of information, the principalVW uses of the data are to provide facts regarding routine occupationalexposures to radiation and radioactive material that occur in connection withNRC-licensed activities, including individual and collective radiation dosesfrom external sources as well as pertinent information on the inhalation ofradioactive material (nuclides involved, bioassay results, exposure magnitude,etc.) These facts are used by the NRC staff as indicated below:1. The external-dose data permit evaluation of the'radiological riskassociated with NRC-licensed activities, including the size of theworkforce and the collective dose.2. The data permit evaluation, from the viewpoint'of trends, of theeffectiveness of the overall NRC/licensee radiation protection and ALARAefforts. They also provide for the identification (and subsequentcorrection) of unfavorable trends.3. The data provide for governmental monitoring of the potential transient-worker problem.4. The data are used in the establishment of priorities for the utilizationof NRC health physics resources: research, standards development,regulatory program development.5. The data are considered in reviews of inspection frequencies that areprogrammed 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 protectionperformance: US/foreign, BWR's/PWR's, civilian/military, plant by plant,nuclear industry with other industries, etc.8. The data permit analysis of annual dose distribution changes which cantrigger investigations as to the cause.9. The data are used for purposes of justification in the annual budgetprocess.10. The data provide facts for evaluating the adequacy of the currentrisk-limitation system (e.g., are individual lifetime dose limits, workerpopulation 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 thecollective dose).12. The data provide facts for answering Congressional and Administrationinquiries and for responding to questions raised by public interestgroups, special interest groups, labor unions, etc.13. The data permit comparisons of occupational radiation risks withpotential public risks when action for additional protection of thepublic involves worker exposures.14. The data provide information which can be used in the planning ofepidemiological studies.-With regard to routine work-place conditions, the annual statistical summaryreports required by 20.407, the termination reports required by §20.408, andthe annual dose data reported by work function in accordance with Subsection6.9.1.5 of the standard technical specifications for nuclear power plantsprovide the only centralized data base available to assist the staff in theperformance of its duties as listed above. It is to everyone's advantage ifthese duties are performed by a well-informed staff in the light of factualinformation.2 NRC FORM 419 U.S. NUCLEAR REGULATORY COMMISSION I- DATE Of REPORT10 CFR im0 401REPORT OF TERMINATING INDIVIDUAL'S 2 NRC UCENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDM4DUAL flet. wmd k"a lest) AND ADDRESS WtionafiB. NAME AND ADDRESS OF EMPLOYER. IF OIFFERENT FROM ABOVE 1tonafl.SOCIAL SECURITY NUMBER l a DATE OF I MONTHI DAY I YEARm BIRTHPART 11. EXTERNAL DOSE DATA18 PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI OF EXPOSURE DEEP WHOSHALLOW Iskint It K Im REMITY OMteerlust date Am)t TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW bk~mfPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.18. BIOASSAY RESULTS 17. DOSE ESTIMATES 1rms)13. PERIODISI OF EXPOSURE 13. INTAKEAiate Alt 14 U NUCLIDE 15. FORM a.IN VIVO InCil It. URINALYSIS a. COM b. ANNUAL c. ORGAN IMPC-Hre.1fefetis.,I RESULTS I Li MITTED DOSEIlI BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.YES (Thi report 6 Awrnd to vou uider the provaion of Ite Nucfu RepuYtwy Commdersua regulatmon 10 CFR Pert 19. Yu should Prserv rho report far fue mrefrmce INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating individual's Occupational ExposureIf 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 exposure reportson eetain individuals to the Director. Oflice of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is so be taken fromdose 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 standards for die wholebody, 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 thisreport 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 "dose equivalent"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 terminationand 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. "Termination" isdefined in 120 3(X 19). Pans 1 and MI of this form reflect regulatory requirements as well as requests intended to standardize reporting methods, requests are clearly identified assuch.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 applicable. Enter thefowing data:ITEM NUMBERDate 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 thelicense 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 numbersin 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 DATAFor the purpose of this form. the deep dose is defined as the dose tasesed at tissue depth of 300 or 1.000 mg/cm' (or less). the shallow dose is defined as the dose to the sin ofany 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 VGUJIvwrJE9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your ficility(s) pursuant to 520202 You are requeted to use an-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 forsubsequent annual Increments.QUARTER: For each eompleted qlarter or bhe 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);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 whichhas 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 ofrecord 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 theextremities (hands and forearms feet and ankles).IOc For anl skin 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 dosedelivered by all radiation Incident on the skin, icluding non-trivial doses from skin contamination, which petates to the depth at which the shallow doseis 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 entryin 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 theeoetributw1iin&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 typespecified 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 ofunknown 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 wasexoed peuda response that you considered to be statistically indistinguishable from the response cae by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or Its equivalent) to a teal number; although NRC regulations do not speciy a summation procedure. theNRC 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 statisticalandyses.-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 tospeciy 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 is determined. hedose at depth of 7 mgfcm5 or less ih acceptable. If Column II is lft blank. it will be assumed that the entry in l0c is applicable also for the extremitydose; an entry in Column II is required only if the hiallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 required to submit ter-mination reports on personnel exposures to radioactive material. contaning information that you have obtained In compliance with the license and' recorded in compliance withV20.401. 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 in compliancewith 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) of the reportingmethods may be ued. The term "individual" is used below to represent the worker for whom this report is submitted. The term "exposures to radioactive material" is used in con-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 ormeasurements 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: spprline. enter the number (including ero) of detectable measurements followed inparenthesis by the highest verified result. if any; lower line, enter deue r finincluding eero) of mesurements indicating undetectable amounts.


SUBJECT: 10 CFR 20.408 TERMINATION REPORTS -FORMATGENERIC LETTER NO. 85-08Pursuant to 10 CFR 20.408, licensees are required to submit to the NRC areport of each individual's exposure to radiation and radioactive materialwhen the individual terminates employment or work assignment at theirfacility. These exposure reports are commonly referred to as §20.408termination reports.Previously, we have not specified a preferred reporting format for compliancewith this regulation. However, the NRC is currently receiving approximately100,000 termination reports each year, and this number is steadily increasing.For purposes of efficient automatic data processing, it is important to use astandard format. Processing in a more timely fashion will make the data moreuseful to the NRC and others in their performance of various duties (seeEnclosure 1).For future §20.408 termination reports we request that you voluntarily use theattached Standard NRC Form-439. Instructions for completing the form are attachedto the form. Questions regarding these instructions should be directed to BarbaraG. Brooks, Office of Nuclear Regulatory Research, Washington, D. C. 20555,(301) 427-4577.The NRC is also conducting a pilot program for the electronic transmissionof the termination data to the NRC via computer tapes or by direct linkup tothe NRC's computing facility, and we would like to encourage you to considerparticipating. Should you desire more information about this program pleasecontact Ms. Brooks.The form is intended for use in connection with the information collectionrequirement established in Section 20.408, 10 CFR Part 20 and approved underOMB Clearance Number 3150-0014.ompson, JN*, Dir oro viion of Licensfng /g1/O ce of Nuclear Reactot egulation
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (ContinuedlCOLUMN NUMBER13 WContinuedl Column 13 Column 14 Column 1 Coluhnm 1616a(1l 1621 Itib (pCUL)1932 U-nat 1 0 luns 2l)2 lung 1019S3 U-nat(Th 2341 1 It71 luns 4(61I lung S19S4 U-nat(Th 2341 1 21141 lung 124310 lung 0Units 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 arm unnecessary.If the dose commitment 150-year integrated dosel is reported. indicate in Column 13 by beginning and ending dates (month, day. year) the period duringwhich 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 ofthis 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 ofradioactive material. using annual increments up to the year of termination and increments not to exceed one quarter for te year in which the individualterminated. 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 forsubsequent 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 urinalysismeasuremtents were performed (e.g.. Co 6D. U 2351. If the measured quantity of activity for one radionuclide is also used to estimage other radionuclidequantities. identify the radionuclide actually measured in parentheses immediately slter die radimonuclide listed in Coluns 14. See the example given is thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tn234 phoon=s15 Enter die fonts. S for soluble or I for insoluble. of die radionuclide to which the worker was exposed. If unknown. use quotes around the leter thus indicating which concentration value in Part 20. Appendix S. Table 1. Columa I. was assumed 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. Youmay 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.a41 the number of detectablemeasurements followed by the highest verified result (in nancocuries) in parentheses. On the next line in this column. enter the number of measurements thatindicated undetectable amounts. Specify in Column 16.2) the organ in which the indicated radionuclide was found. Se the example given in the directionsfor Column 13.16b First. enter the gravimetric or radiometric unit in which the urinalysis results are reported te.g.. micrograms per liter. nanocuries per liter) in the blankspace of the heading for Column 16b. Is Column 16b. for each year during which urinalyses were performed. enter die number of detectable resultfollowed 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 thenext 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 commnittedand annual doses.) For Columns 17a and 17b you ar requested to follow dut procedures below: if ay alternative procedures are used, describe the.n ondie 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 assignmentand the year following tde termination date. Base dose estimates on the quantity las a minimuni of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column1l.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 ataisfy the notification requirement of 10 CFR 19.13. check the "Yes" box.PRIVACY ACT STATEMENTPursuant 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 whosupply information to the Nuclear Regulatory Commission on NRC Form 439. This information is maintatined in a system of records designated as NRC-27 and described at 40Federal 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  
 
===Enclosure:===
1.Ues-of Radiation Exposure Data I2. Five copies of NRC Form 439c i L ttflenercilel;1ers -g>8505210106PDQI A-DOCK O 500L Uses of Radiation Exposure DataA number of NRC licensees have inquired as to how occupational-radiationexposure data (from reports required by the NRC)'are used by the NRC staff.This is a very appropriate inquiry that may be of importance' to many affectedlicensees. In combination with other sources of information, the principalVW uses of the data are to provide facts regarding routine occupationalexposures to radiation and radioactive material that occur in connection withNRC-licensed activities, including individual and collective radiation dosesfrom external sources as well as pertinent information on the inhalation ofradioactive material (nuclides involved, bioassay results, exposure magnitude,etc.) These facts are used by the NRC staff as indicated below:1. The external-dose data permit evaluation of the'radiological riskassociated with NRC-licensed activities, including the size of theworkforce and the collective dose.2. The data permit evaluation, from the viewpoint'of trends, of theeffectiveness of the overall NRC/licensee radiation protection and ALARAefforts. They also provide for the identification (and subsequentcorrection) of unfavorable trends.3. The data provide for governmental monitoring of the potential transient-worker problem.4. The data are used in the establishment of priorities for the utilizationof NRC health physics resources: research, standards development,regulatory program development.5. The data are considered in reviews of inspection frequencies that areprogrammed 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 protectionperformance: US/foreign, BWR's/PWR's, civilian/military, plant by plant,nuclear industry with other industries, etc.8. The data permit analysis of annual dose distribution changes which cantrigger investigations as to the cause.9. The data are used for purposes of justification in the annual budgetprocess.10. The data provide facts for evaluating the adequacy of the currentrisk-limitation system (e.g., are individual lifetime dose limits, workerpopulation 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 thecollective dose).12. The data provide facts for answering Congressional and Administrationinquiries and for responding to questions raised by public interestgroups, special interest groups, labor unions, etc.13. The data permit comparisons of occupational radiation risks withpotential public risks when action for additional protection of thepublic involves worker exposures.14. The data provide information which can be used in the planning ofepidemiological studies.-With regard to routine work-place conditions, the annual statistical summaryreports required by 20.407, the termination reports required by §20.408, andthe annual dose data reported by work function in accordance with Subsection6.9.1.5 of the standard technical specifications for nuclear power plantsprovide the only centralized data base available to assist the staff in theperformance of its duties as listed above. It is to everyone's advantage ifthese duties are performed by a well-informed staff in the light of factualinformatio NRC FORM 419 U.S. NUCLEAR REGULATORY COMMISSION I- DATE Of REPORT10 CFR im0 401REPORT OF TERMINATING INDIVIDUAL'S 2 NRC UCENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDM4DUAL flet. wmd k"a lest) AND ADDRESS WtionafiB. NAME AND ADDRESS OF EMPLOYER. IF OIFFERENT FROM ABOVE 1tonafl.SOCIAL SECURITY NUMBER l a DATE OF I MONTHI DAY I YEARm BIRTHPART 11. EXTERNAL DOSE DATA18 PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI OF EXPOSURE DEEP WHOSHALLOW Iskint It K Im REMITY OMteerlust date Am)t TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW bk~mfPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.18. BIOASSAY RESULTS 17. DOSE ESTIMATES 1rms)13. PERIODISI OF EXPOSURE 13. INTAKEAiate Alt 14 U NUCLIDE 15. FORM a.IN VIVO InCil It. URINALYSIS a. COM b. ANNUAL c. ORGAN IMPC-Hre.1fefetis.,I RESULTS I Li MITTED DOSEIlI BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.YES (Thi report 6 Awrnd to vou uider the provaion of Ite Nucfu RepuYtwy Commdersua regulatmon 10 CFR Pert 19. Yu should Prserv rho report far fue mrefrmce INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating individual's Occupational ExposureIf 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 exposure reportson eetain individuals to the Director. Oflice of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is so be taken fromdose 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 standards for die wholebody, 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 thisreport 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 "dose equivalent"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 terminationand 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. "Termination" isdefined in 120 3(X 19). Pans 1 and MI of this form reflect regulatory requirements as well as requests intended to standardize reporting methods, requests are clearly identified assuch.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 applicable. Enter thefowing data:ITEM NUMBERDate 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 thelicense 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 numbersin 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 DATAFor the purpose of this form. the deep dose is defined as the dose tasesed at tissue depth of 300 or 1.000 mg/cm' (or less). the shallow dose is defined as the dose to the sin ofany 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 VGUJIvwrJE9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your ficility(s) pursuant to 520202 You are requeted to use an-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 forsubsequent annual Increments.QUARTER: For each eompleted qlarter or bhe 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);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 whichhas 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 ofrecord 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 theextremities (hands and forearms feet and ankles).IOc For anl skin 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 dosedelivered by all radiation Incident on the skin, icluding non-trivial doses from skin contamination, which petates to the depth at which the shallow doseis 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 entryin 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 theeoetributw1iin&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 typespecified 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 ofunknown 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 wasexoed peuda response that you considered to be statistically indistinguishable from the response cae by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or Its equivalent) to a teal number; although NRC regulations do not speciy a summation procedure. theNRC 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 statisticalandyses.-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 tospeciy 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 is determined. hedose at depth of 7 mgfcm5 or less ih acceptable. If Column II is lft blank. it will be assumed that the entry in l0c is applicable also for the extremitydose; an entry in Column II is required only if the hiallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 required to submit ter-mination reports on personnel exposures to radioactive material. contaning information that you have obtained In compliance with the license and' recorded in compliance withV20.401. 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 in compliancewith 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) of the reportingmethods may be ued. The term "individual" is used below to represent the worker for whom this report is submitted. The term "exposures to radioactive material" is used in con-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 ormeasurements 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: spprline. enter the number (including ero) of detectable measurements followed inparenthesis by the highest verified result. if any; lower line, enter deue r finincluding eero) of mesurements indicating undetectable amount INSTRUCTIONS FOR COMPLETING NRC FORM 439 (ContinuedlCOLUMN NUMBER13 WContinuedl Column 13 Column 14 Column 1 Coluhnm 1616a(1l 1621 Itib (pCUL)1932 U-nat 1 0 luns 2l)2 lung 1019S3 U-nat(Th 2341 1 It71 luns 4(61I lung S19S4 U-nat(Th 2341 1 21141 lung 124310 lung 0Units 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 arm unnecessary.If the dose commitment 150-year integrated dosel is reported. indicate in Column 13 by beginning and ending dates (month, day. year) the period duringwhich 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 ofthis 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 ofradioactive material. using annual increments up to the year of termination and increments not to exceed one quarter for te year in which the individualterminated. 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 forsubsequent 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 urinalysismeasuremtents were performed (e.g.. Co 6D. U 2351. If the measured quantity of activity for one radionuclide is also used to estimage other radionuclidequantities. identify the radionuclide actually measured in parentheses immediately slter die radimonuclide listed in Coluns 14. See the example given is thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tn234 phoon=s15 Enter die fonts. S for soluble or I for insoluble. of die radionuclide to which the worker was exposed. If unknown. use quotes around the leter thus indicating which concentration value in Part 20. Appendix S. Table 1. Columa I. was assumed 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. Youmay 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.a41 the number of detectablemeasurements followed by the highest verified result (in nancocuries) in parentheses. On the next line in this column. enter the number of measurements thatindicated undetectable amounts. Specify in Column 16.2) the organ in which the indicated radionuclide was found. Se the example given in the directionsfor Column 13.16b First. enter the gravimetric or radiometric unit in which the urinalysis results are reported te.g.. micrograms per liter. nanocuries per liter) in the blankspace of the heading for Column 16b. Is Column 16b. for each year during which urinalyses were performed. enter die number of detectable resultfollowed 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 thenext 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 commnittedand annual doses.) For Columns 17a and 17b you ar requested to follow dut procedures below: if ay alternative procedures are used, describe the.n ondie 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 assignmentand the year following tde termination date. Base dose estimates on the quantity las a minimuni of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column1l.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 ataisfy the notification requirement of 10 CFR 19.13. check the "Yes" box.PRIVACY ACT STATEMENTPursuant 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 whosupply information to the Nuclear Regulatory Commission on NRC Form 439. This information is maintatined in a system of records designated as NRC-27 and described at 40Federal 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==
==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 itsstatutory 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 request3. 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarydot 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 accurateidentifier 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 thelicease must file a termination report containing tertain required information, such as social security number. for each individual wvhos employmnent or work assignment hasterminated and for whomt personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the informatdon under 10 CFl 120.202 and 20.403 maysubject the licensee to enforcement action under 10 CFl 20.601.S. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CotmmiminWaishingt. DC 20555 NRC FORM 41 U.S. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT10 CFR _20.4__REPORT OF TERMINATING INDIVIDUALS 2. NRC UQCENSE NUMBER4SIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. 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 1006onafl6. SOCIAL SECURITY NUMBER I MONTH I DAY I YEAR7. DATE OFB IRTHPART II. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI Of EXPOSURE DEEP 10 WHOLE BODY SHALLFW t i. EXTEMITY DOSE Anda. TOt
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 itsstatutory 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 request3. 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarydot 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 accurateidentifier 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 thelicease must file a termination report containing tertain required information, such as social security number. for each individual wvhos employmnent or work assignment hasterminated and for whomt personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the informatdon under 10 CFl 120.202 and 20.403 maysubject the licensee to enforcement action under 10 CFl 20.601.S. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CotmmiminWaishingt. DC 20555 NRC FORM 41 U.S. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT10 CFR _20.4__REPORT OF TERMINATING INDIVIDUALS 2. NRC UQCENSE NUMBER4SIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. 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 1006onafl6. SOCIAL SECURITY NUMBER I MONTH I DAY I YEAR7. DATE OFB IRTHPART II. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI Of EXPOSURE DEEP 10 WHOLE BODY SHALLFW t i. EXTEMITY DOSE Anda. TOt
* s i OTAL b. NEUTRON c. TOTAL d. BETA SHALLOWPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALl12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tmot13. PERIDDISI OF EXPOSURE lB. INTAKE1.PRIOD dt fEPU U. NUCLIDE 15 FORM a. IN VIVO InMC b. URINALYSIS S. COM- b.ANNUAL c. ORGAN IMPC NHr.lIs. II -ESULTS I LI MITTED DOSEI. BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS20. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION 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 ,rfwnc INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individual's Occupational ExposureIf 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 reportson certain individuals to the Director, Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Comnmission. Washington. DC 20555. This information is to be taken fromdose 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 wholebody. 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 thisreport 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 terminationand 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" isdefined in 520.3(a)(19). Parts 1 and 11l of this form reflect regulatory requiremnents as well as requests intended to standardize reporting methods- requests re clearly identified assuch.PART 1 LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin the order of original issuance3 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.I5 The name and 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 DATAFor 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 so the skin ofany 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 So check the box to the left nd go to Part 11.COLUMN NUMBER9 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 fort 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin, including non-trivial doses from skin contamination. which penetrates to the depth at which the shallow doseis 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 entryin 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 theeontribution 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 typespecified 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 ofuvknown 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 wasexposed pic a response tdat you considered to be statistically indistinguishable from dte response cused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or its equivalent) to a real number, although NRC regulations do sot specify a summation procedure. theNRC 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 statisticalanalyses.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 and ankles during the reported period. It is unnecessary Iospecify 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 ia determined. Thedose 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 fan entry in Cohumn II is required only if the shallow dose exceeded the deep dose.PART I. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 compliancewith 120.401. This part provides for due reporting of internal monitoring procedures in tenns of bioassay results, dose estimates, or intake. Any one (or more) of these reportingmethods 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 ofmasufletnents 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: pper line. enter the number (including Mero) of detectable Measurenients followed inparenthesis by the highest verified result, if any; lower line, enter am number (including zero) of measurements indicating undetectable armount INSTRUClIONS FOR COMPLETING NRC FORM 439 (ContiICOLUMN NUMBER13 (Continued) Column 13 Column 14 Column 15 Column 1616d l l 166l21 lt~b (pCit1982 U-nat 1 0 lung 2(1-2 lung 1019S3 U-nattTh 2341 2 lC? lung 4463I lung S1984 U-natfih 234 1 2041 lung 1241330 lung 0Units 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. notations 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 duringwhich 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 ofthis~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 ofradioactive material, using annual increments up to die yea of termination and increments not to exceed one quarter for the year in which the individualterminated. 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 forsubsequent 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 urinalysimeasurements were performed (e.g.. Co 60. U 2353. If the measured quantity of activity for one radionuclide is also used to estimate other radionuclidequantities. identify die radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2342 is entered in Column 14 indicating that the uranium lung burden was determined fron measurements ofTh234 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. Youmay 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 detectablemeasurements followed by the highest verified result (in nanocuriesi in parentheses. On the next line in this column, enter the number of measurements thatindicated undetectable amounts. Specify in Column 16at2) the organ in which the indicated radionuclide was found. See the example gives in tde directionsfor 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 blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the number of detectable resultsfollowed 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 thenext 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 committedand annual doses.) For Columns I7b and 17b you we requested to follow the procedures below: if any alternative procedures are used, describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (as a minimum) of the radionuclide. Column 14. taken into the body atyour facilityts) during ;his employment or work-assignment period.IS Reporting of radionuclide intakesa as determined by sir sampling, is not required by 10 CFR 20408. However, should thia option be chosen, indicate thetime-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 Columnla.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 STATEMENTPtruant 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 whosupply 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 40Federal 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  
* s i OTAL b. NEUTRON c. TOTAL d. BETA SHALLOWPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALl12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tmot13. PERIDDISI OF EXPOSURE lB. INTAKE1.PRIOD dt fEPU U. NUCLIDE 15 FORM a. IN VIVO InMC b. URINALYSIS S. COM- b.ANNUAL c. ORGAN IMPC NHr.lIs. II -ESULTS I LI MITTED DOSEI. BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS20. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION 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 ExposureIf 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 reportson certain individuals to the Director, Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Comnmission. Washington. DC 20555. This information is to be taken fromdose 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 wholebody. 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 thisreport 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 terminationand 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" isdefined in 520.3(a)(19). Parts 1 and 11l of this form reflect regulatory requiremnents as well as requests intended to standardize reporting methods- requests re clearly identified assuch.PART 1 LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin the order of original issuance3 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.I5 The name and 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 DATAFor 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 so the skin ofany 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 So check the box to the left nd go to Part 11.COLUMN NUMBER9 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 fort 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin, including non-trivial doses from skin contamination. which penetrates to the depth at which the shallow doseis 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 entryin 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 theeontribution 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 typespecified 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 ofuvknown 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 wasexposed pic a response tdat you considered to be statistically indistinguishable from dte response cused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or its equivalent) to a real number, although NRC regulations do sot specify a summation procedure. theNRC 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 statisticalanalyses.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 and ankles during the reported period. It is unnecessary Iospecify 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 ia determined. Thedose 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 fan entry in Cohumn II is required only if the shallow dose exceeded the deep dose.PART I. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 compliancewith 120.401. This part provides for due reporting of internal monitoring procedures in tenns of bioassay results, dose estimates, or intake. Any one (or more) of these reportingmethods 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 ofmasufletnents 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: pper line. enter the number (including Mero) of detectable Measurenients followed inparenthesis 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 (ContiICOLUMN NUMBER13 (Continued) Column 13 Column 14 Column 15 Column 1616d l l 166l21 lt~b (pCit1982 U-nat 1 0 lung 2(1-2 lung 1019S3 U-nattTh 2341 2 lC? lung 4463I lung S1984 U-natfih 234 1 2041 lung 1241330 lung 0Units 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. notations 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 duringwhich 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 ofthis~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 ofradioactive material, using annual increments up to die yea of termination and increments not to exceed one quarter for the year in which the individualterminated. 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 forsubsequent 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 urinalysimeasurements were performed (e.g.. Co 60. U 2353. If the measured quantity of activity for one radionuclide is also used to estimate other radionuclidequantities. identify die radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2342 is entered in Column 14 indicating that the uranium lung burden was determined fron measurements ofTh234 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. Youmay 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 detectablemeasurements followed by the highest verified result (in nanocuriesi in parentheses. On the next line in this column, enter the number of measurements thatindicated undetectable amounts. Specify in Column 16at2) the organ in which the indicated radionuclide was found. See the example gives in tde directionsfor 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 blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the number of detectable resultsfollowed 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 thenext 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 committedand annual doses.) For Columns I7b and 17b you we requested to follow the procedures below: if any alternative procedures are used, describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (as a minimum) of the radionuclide. Column 14. taken into the body atyour facilityts) during ;his employment or work-assignment period.IS Reporting of radionuclide intakesa as determined by sir sampling, is not required by 10 CFR 20408. However, should thia option be chosen, indicate thetime-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 Columnla.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 STATEMENTPtruant 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 whosupply 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 40Federal 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==
==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 itsstatutory 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 byindividuals employed as radiation workers on a permanent or temporary bass and exposure received by monitored visitors. The Wormatio may also be disclosed to an appirops 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. k is voluntarythat 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 accurateidentifier 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 thelicemiee must file a termination report containing certain required information, such as social security number, for each individual whose employment or work assignment hasterminated 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 maysubject the licensee to enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERLS3 AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissiinWashington. DC 20555 NRC FORM U.S. NUCLEAR REGULATORY COMMISSION I. TOF REPORT10 CMR p0.411REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA2. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDIVIDUAL tMMt. mte hmdli est) AND ADDRESS boItorlS. NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE IO(tlnallt. SOCIAL SECURITY NUMBER M7. DATE OF I ONTH I DAY I YEARI BIRTHPART 11. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED._ 9. PERODS OF EXPOSURE DEEP 10 WHOLE BODY D ALWt )I I. EXTREMITY DOSE froml3.PRoCsI Of dEXPoSUElE SHALLOW take,)a. TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW tintPART Ill. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL_12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tnml13. PERIOCISI OF EXPOSURE 14. NUCUADE IS FORO IO. INTAKEVeretdpte A A.NULDE 16 FR a. IN VIVO InCiI b. URINALYSIS S. COM- b. ANNUAL c. ORGAN 4MPC.HrsIis. II RESULTS I LI MITTED DOSEIll BURDEN t21 ORGAN DOSE19. OTHER BIOASSAY RESULTS0. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF tO CR 19.13. CHECK THE FOLLOWING BOX.YES IThise m fian ted to VW rw lew povmion of VWe NdlRoar ltovy CG m ons regulaton 10 CFR Part 19. Yu. amaw waew ,w mqhwt AN Athr rferme.)
(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 itsstatutory 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 byindividuals employed as radiation workers on a permanent or temporary bass and exposure received by monitored visitors. The Wormatio may also be disclosed to an appirops 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. k is voluntarythat 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 accurateidentifier 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 thelicemiee must file a termination report containing certain required information, such as social security number, for each individual whose employment or work assignment hasterminated 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 maysubject the licensee to enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERLS3 AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissiinWashington. DC 20555 NRC FORM U.S. NUCLEAR REGULATORY COMMISSION I. TOF REPORT10 CMR p0.411REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA2. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDIVIDUAL tMMt. mte hmdli est) AND ADDRESS boItorlS. NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE IO(tlnallt. SOCIAL SECURITY NUMBER M7. DATE OF I ONTH I DAY I YEARI BIRTHPART 11. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED._ 9. PERODS OF EXPOSURE DEEP 10 WHOLE BODY D ALWt )I I. EXTREMITY DOSE froml3.PRoCsI Of dEXPoSUElE SHALLOW take,)a. TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW tintPART Ill. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL_12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tnml13. PERIOCISI OF EXPOSURE 14. NUCUADE IS FORO IO. INTAKEVeretdpte A A.NULDE 16 FR a. IN VIVO InCiI b. URINALYSIS S. COM- b. ANNUAL c. ORGAN 4MPC.HrsIis. II RESULTS I LI MITTED DOSEIll BURDEN t21 ORGAN DOSE19. OTHER BIOASSAY RESULTS0. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF tO CR 19.13. CHECK THE FOLLOWING BOX.YES IThise m fian ted to VW rw lew povmion of VWe NdlRoar ltovy CG m 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 ExposureIf 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 reportson certain individuals to the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regubatosy Commission. Washington. DC 20555. This infornation is to be taken fromdose 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 wholebody, 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 thisrepor 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 ternninationaid 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" isdefined in 120.3tXt19). Parts U and 11l of this form reflect regulatory requirements as well as requests intended to standardize reporting methods: requests are dearly identified assuch.PART I LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 dhe skin ofany 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 NUMBER9 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 noo to 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 forbsequent 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin. including non-trivial doses from Skin contamionaion, which penettes to the depth at which the shallow doseis determirne. The dose st a depth of 7 mgeimn or less, averaged over I cm'. is acceptasle. If Column Ilk is left blank. it will be assumed that the entryin 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, mnd to enter in Column l0d theeontributiiinudeby beta radiation to the dose reported in Column lOc. Enter XXX if it is known that there was no exposure to radiation of the typespecified 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 Ofunknown magniude.10 & 11 You re r bt enter mn or zao (in each colurnr of 10. or in II) if the dose was undetectable. ie.. the radiation to which the worker's dosimeter wasexposed produc a response that you considered to be statistically indistinguishable from dhe response esused by inherent varibilities o the dosmetersystem. Note It is sometmcs required to add m (or its equivalent) to a real number; although NRC regulations do nut specify a summation procedure. theNRC 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 statisticalanalyses.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 hMnds and foreans or feet tad ankles during the reported period. It is unnecessary tospecify 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 dete rmined. Thedose 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 extremitydose; a ensy in Column II is required only if the shallow dos exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The term "individual" is used below to represent hie worker hor whom 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 nto monitored 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 ofmeasurements which indicated quantities or concenurationsV were 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b : Iine enter dhe number (including zero) of detectable measurements followed inparenthesis by th highest verified result if ny lower line, enter thenumber Including zero) of measurements indicating undetectable amounts.


INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individual s Occupational ExposureIf 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 reportson certain individuals to the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regubatosy Commission. Washington. DC 20555. This infornation is to be taken fromdose 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 wholebody, 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 thisrepor 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 ternninationaid 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" isdefined in 120.3tXt19). Parts U and 11l of this form reflect regulatory requirements as well as requests intended to standardize reporting methods: requests are dearly identified assuch.PART I LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 dhe skin ofany 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 NUMBER9 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 noo to 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 forbsequent 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin. including non-trivial doses from Skin contamionaion, which penettes to the depth at which the shallow doseis determirne. The dose st a depth of 7 mgeimn or less, averaged over I cm'. is acceptasle. If Column Ilk is left blank. it will be assumed that the entryin 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, mnd to enter in Column l0d theeontributiiinudeby beta radiation to the dose reported in Column lOc. Enter XXX if it is known that there was no exposure to radiation of the typespecified 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 Ofunknown magniude.10 & 11 You re r bt enter mn or zao (in each colurnr of 10. or in II) if the dose was undetectable. ie.. the radiation to which the worker's dosimeter wasexposed produc a response that you considered to be statistically indistinguishable from dhe response esused by inherent varibilities o the dosmetersystem. Note It is sometmcs required to add m (or its equivalent) to a real number; although NRC regulations do nut specify a summation procedure. theNRC 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 statisticalanalyses.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 hMnds and foreans or feet tad ankles during the reported period. It is unnecessary tospecify 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 dete rmined. Thedose 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 extremitydose; a ensy in Column II is required only if the shallow dos exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The term "individual" is used below to represent hie worker hor whom 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 nto monitored 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 ofmeasurements which indicated quantities or concenurationsV were 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b : Iine enter dhe number (including zero) of detectable measurements followed inparenthesis by th highest verified result if ny lower line, enter thenumber Including zero) of measurements indicating undetectable amount INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 iContinuled Column 13 Column 14 Column IS Column 1616aglI 16t421 16b (IpClL.19J2 U-nat 1 0 lung 2(232 lung 101913 U-nat(Th 2343 ..I. 1t71 lung 4(61I lung a1984 U-natth 2343 ..I. 2tl41 lung 121330 lung 0Units orr the 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 duringwhich 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 ofthis 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 ofradioactive material. using annual incremnts up to the year of termination and increments not to exceed one quarter for the year in which the individualterminated. The periods of exposure for intakes should appear as follows:ANNUAL: Indicate doe monds and year of the beginning date of exposure when showing annual incremtents (e.g.. June 923) ;and indicate the year only forsubsequent annual increments.QUARTER: For each completed quarter of the yer of termination, indicate the quarter and year by dateCURRENT 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 urinalysirmeasurements were performed (e.g.. Co 60. U 2351. If the measured quantity of activity fcr one radionuclide is also used to estimate other radlonuclidequantities. identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined fromt measurements of Th234 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. Youmay use one or more of doese methods.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 detectablemeasurements followed by the highest verified result (in nanocuriesi is parentheses. On the next line in this column, enter the number of neasuremen thatindicated undetectable amounts. Specify in Column 16a42) the organ in which the indicated radionuclide war found. See die example given in the directionsfor 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 blankspace of the heading for Column 26b. In Column 16b. for each year during which urinalyses were performed. enter the nruber of detectable resultsifollowed 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 thenext line in this column. enter the number of measurements indicating undetectable amounts. See die 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 conmittedand annual doses.) For Columns 17. and 17b you are requested to follow die procedures below: if any alternative procedures are used. describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (ts a minimuml of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column12.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 STATEMENTPursuant 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 whosupply 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 40Federal Register 45344 (October 1. 1975p.1. AUTHORITY. Sections 53. 63. 65. 21. 103. 104. 161(bl. and 161(3 of dthe 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  
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 iContinuled Column 13 Column 14 Column IS Column 1616aglI 16t421 16b (IpClL.19J2 U-nat 1 0 lung 2(232 lung 101913 U-nat(Th 2343 ..I. 1t71 lung 4(61I lung a1984 U-natth 2343 ..I. 2tl41 lung 121330 lung 0Units orr the 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 duringwhich 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 ofthis 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 ofradioactive material. using annual incremnts up to the year of termination and increments not to exceed one quarter for the year in which the individualterminated. The periods of exposure for intakes should appear as follows:ANNUAL: Indicate doe monds and year of the beginning date of exposure when showing annual incremtents (e.g.. June 923) ;and indicate the year only forsubsequent annual increments.QUARTER: For each completed quarter of the yer of termination, indicate the quarter and year by dateCURRENT 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 urinalysirmeasurements were performed (e.g.. Co 60. U 2351. If the measured quantity of activity fcr one radionuclide is also used to estimate other radlonuclidequantities. identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined fromt measurements of Th234 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. Youmay use one or more of doese methods.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 detectablemeasurements followed by the highest verified result (in nanocuriesi is parentheses. On the next line in this column, enter the number of neasuremen thatindicated undetectable amounts. Specify in Column 16a42) the organ in which the indicated radionuclide war found. See die example given in the directionsfor 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 blankspace of the heading for Column 26b. In Column 16b. for each year during which urinalyses were performed. enter the nruber of detectable resultsifollowed 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 thenext line in this column. enter the number of measurements indicating undetectable amounts. See die 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 conmittedand annual doses.) For Columns 17. and 17b you are requested to follow die procedures below: if any alternative procedures are used. describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (ts a minimuml of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column12.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 STATEMENTPursuant 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 whosupply 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 40Federal Register 45344 (October 1. 1975p.1. AUTHORITY. Sections 53. 63. 65. 21. 103. 104. 161(bl. and 161(3 of dthe 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==
==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 itsstatutory 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested information, including name. date of birsh. and social security number. The social security number is used to assire that NRC has an accurateidentifier 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 thelicensee must file a termination report containing certain required information, such as social security number. for each individual whose employment or work assignment hasterminated 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 maysubject the licensee lo enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERtS) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissionWashington. DC 2055 NRC FORM 439 U.S. NUCLEAR REGULATORY COMMISSION .DATE OF REPORT4J51 -10 CFR J20.t0REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUTABERISOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDMDUAL mit. mWlde t. Ilal AND ADDRESS kptta5S NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE tOotbirfgl. SOCIAL SECURITY NUMBER l7. ATE OF I MONtH I DAY I YEARI BIRTHPART II. EXTERNAL DOSE DATAIS PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.10 WHOLE BODY OOSF ImP A 11. EXTREMITY DOSE (mu)S. PERIODtSI OF EXFOSURE DEE SHLLWE P kir doe rwt .TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW ftahIFPART Il. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.I6. BIOASSAY RESULTS 17. DOSE ESTIMATES (umm)u13. PERt)OISI OF EXPOSURE 14. NUCLIOE tS 11 VNO InCil b. URINALYSIS S. L COM I A C. ORGAN KSTE13. 14. NUCLIDE IS ORMAN.UINLVIVO IANlIMPC-Hrs.1trts tewil(S. II RESULTS I Li MITTED, DOSE(Il BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2X. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REQUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.I YESrTo won lsaporrns d to wNdt e DpnOvi of the Maclw ReguLatory Coalason's rgulcian I0 CFR Prt 19. Vouf *tprsww Iw for ilar b b fe .I INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individua's Occupational ExposureIf 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 reportson certain individuals so the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is lo be taken fromdose records ltht must be maintained under 120.401 for individuals likely to receive exposure so radiation that exceeds a certain percentage of the NRC dose standards for die wholebody, 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 disreport is submitted. The term dosee as used 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 terminationand 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" isdefined 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 assuch.PART 1. LCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 ofany 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 NUMBER9 Specify the reporting intervals (periods of exposure) that she individual 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 forsubsequent 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 whichhas 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 ofrecord. i.e.. she highest dose received at the selected depth, from all types of external radiation sources, at any location on die body except die skin and theextremities (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 dosedelivered by all radiation incident on bhe skin, including non-trivial doses from skin contamination. which penetrates to die depth at which the shallow doseis determined. The dose at a depth of 7 mg/cm' or less, averaged over I cm2.is acceptable. If Column ICc is left blank. it will be assumed that the entryin 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 so the dose reported in Column 10. and so enter in Column l0d thecontribution 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 typespecified 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 ofunknown mignitude.10 & 11 You we r ested to enter mn or zero (in each column of 10. or in II) if the dose was undetectable. i.e., the radiation to which the worker's dosimeter wasexposed Md* response thlt you considered to be statistically indistinguishable from the response caused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add D (or its equivalent) to a real umber; although NRC regulations do not specify a Summation procedure, theNRC 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 statistianalyses.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 tospecify 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. Thedose 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 extremitydose. an entry in Column II is required only if the shallow dose exceeded the deep dose.PART m. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The erm bidividurd' is used 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 ofmeasurements 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 detectablereults and tie lower line for those undetectable. In 16a and/or 16b: uper I enter die number (including Iaol of detectable measurements followed inparenthesis by the highest verified result, if any: lowea line. enter thd ime ber (including zero) of meaurements iidiatisg undetectble mount INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 WContinucedl Column 13 Column 14 Column 15S Column 16I6dall 162) Itb (pCi/LI19S2 U-nm "I" 0 lung 2l2 tuns 1019S3 U-nauTh 234) 2 If7i luns 4(6)I lung 819S4 U-nst(Th 234) 1 204I tuns 12(130 lung 0Units 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 duringwhich 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 ofthis 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 ofradioactive naterial. using annual increments up to the year of termination and increments not to exceed one quarner for tde year in which the individualterminated. 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 19S31 and indicate the yew only forsubsequent 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 urinalysismeasurements were performed (e.g.. Co 6D. U 235). If the measured quantity of activity for one radlonuclide is also used to estimate other radionuclidequantities, identify the radionuclide actually measurcd in parentheses immediately after die radionmclide listed in Column 14. See the example given ini tedirections for Column 13 where U-nat(Th 234) is entered in Column 14 indicating that the uranium lung burdes was determined from measurements ofTh234 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 around the 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. Youmay 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 detectablemeasurement followed by the highest verified result (is manocuriesl in parheses. Os tde next linte it ths column. enter tde nunber ofd nmaur s thatindicated undetectable amounts. Specify in Column 16a12) the organ in which the indicated radionuclide was found. See the example gives is the directionsfor 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 blankspace of the heading for Column l6b. Is Column lob. for each year during which urinslyses were performed, enter the number of detecutble rsultfollowed 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 tdeneXt 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. (NotW that it is not necessary to provide both the committedand annual doses.) For Columns 17a and l7b you are requested to follow the procedures below: if any alternative procedures are used, describe thie onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (s a minitum) of the radionuclide. Column 14. takes into the body atyour 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 thetime-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 Column18.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 STATEMENTPursuant 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 whosupply 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  
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 itsstatutory 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested information, including name. date of birsh. and social security number. The social security number is used to assire that NRC has an accurateidentifier 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 thelicensee must file a termination report containing certain required information, such as social security number. for each individual whose employment or work assignment hasterminated 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 maysubject the licensee lo enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERtS) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissionWashington. DC 2055 NRC FORM 439 U.S. NUCLEAR REGULATORY COMMISSION .DATE OF REPORT4J51 -10 CFR J20.t0REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUTABERISOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDMDUAL mit. mWlde t. Ilal AND ADDRESS kptta5S NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE tOotbirfgl. SOCIAL SECURITY NUMBER l7. ATE OF I MONtH I DAY I YEARI BIRTHPART II. EXTERNAL DOSE DATAIS PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.10 WHOLE BODY OOSF ImP A 11. EXTREMITY DOSE (mu)S. PERIODtSI OF EXFOSURE DEE SHLLWE P kir doe rwt .TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW ftahIFPART Il. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.I6. BIOASSAY RESULTS 17. DOSE ESTIMATES (umm)u13. PERt)OISI OF EXPOSURE 14. NUCLIOE tS 11 VNO InCil b. URINALYSIS S. L COM I A C. ORGAN KSTE13. 14. NUCLIDE IS ORMAN.UINLVIVO IANlIMPC-Hrs.1trts tewil(S. II RESULTS I Li MITTED, DOSE(Il BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2X. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REQUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.I YESrTo won lsaporrns d to wNdt e DpnOvi of the Maclw ReguLatory Coalason's rgulcian I0 CFR Prt 19. Vouf *tprsww Iw for ilar b b fe .I  
INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individua's Occupational ExposureIf 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 reportson certain individuals so the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is lo be taken fromdose records ltht must be maintained under 120.401 for individuals likely to receive exposure so radiation that exceeds a certain percentage of the NRC dose standards for die wholebody, 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 disreport is submitted. The term dosee as used 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 terminationand 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" isdefined 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 assuch.PART 1. LCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 ofany 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 NUMBER9 Specify the reporting intervals (periods of exposure) that she individual 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 forsubsequent 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 whichhas 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 ofrecord. i.e.. she highest dose received at the selected depth, from all types of external radiation sources, at any location on die body except die skin and theextremities (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 dosedelivered by all radiation incident on bhe skin, including non-trivial doses from skin contamination. which penetrates to die depth at which the shallow doseis determined. The dose at a depth of 7 mg/cm' or less, averaged over I cm2.is acceptable. If Column ICc is left blank. it will be assumed that the entryin 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 so the dose reported in Column 10. and so enter in Column l0d thecontribution 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 typespecified 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 ofunknown mignitude.10 & 11 You we r ested to enter mn or zero (in each column of 10. or in II) if the dose was undetectable. i.e., the radiation to which the worker's dosimeter wasexposed Md* response thlt you considered to be statistically indistinguishable from the response caused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add D (or its equivalent) to a real umber; although NRC regulations do not specify a Summation procedure, theNRC 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 statistianalyses.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 tospecify 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. Thedose 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 extremitydose. an entry in Column II is required only if the shallow dose exceeded the deep dose.PART m. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The erm bidividurd' is used 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 ofmeasurements 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 detectablereults and tie lower line for those undetectable. In 16a and/or 16b: uper I enter die number (including Iaol of detectable measurements followed inparenthesis by the highest verified result, if any: lowea line. enter thd ime ber (including zero) of meaurements iidiatisg undetectble mounts.
 
INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 WContinucedl Column 13 Column 14 Column 15S Column 16I6dall 162) Itb (pCi/LI19S2 U-nm "I" 0 lung 2l2 tuns 1019S3 U-nauTh 234) 2 If7i luns 4(6)I lung 819S4 U-nst(Th 234) 1 204I tuns 12(130 lung 0Units 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 duringwhich 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 ofthis 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 ofradioactive naterial. using annual increments up to the year of termination and increments not to exceed one quarner for tde year in which the individualterminated. 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 19S31 and indicate the yew only forsubsequent 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 urinalysismeasurements were performed (e.g.. Co 6D. U 235). If the measured quantity of activity for one radlonuclide is also used to estimate other radionuclidequantities, identify the radionuclide actually measurcd in parentheses immediately after die radionmclide listed in Column 14. See the example given ini tedirections for Column 13 where U-nat(Th 234) is entered in Column 14 indicating that the uranium lung burdes was determined from measurements ofTh234 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 around the 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. Youmay 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 detectablemeasurement followed by the highest verified result (is manocuriesl in parheses. Os tde next linte it ths column. enter tde nunber ofd nmaur s thatindicated undetectable amounts. Specify in Column 16a12) the organ in which the indicated radionuclide was found. See the example gives is the directionsfor 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 blankspace of the heading for Column l6b. Is Column lob. for each year during which urinslyses were performed, enter the number of detecutble rsultfollowed 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 tdeneXt 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. (NotW that it is not necessary to provide both the committedand annual doses.) For Columns 17a and l7b you are requested to follow the procedures below: if any alternative procedures are used, describe thie onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (s a minitum) of the radionuclide. Column 14. takes into the body atyour 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 thetime-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 Column18.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 STATEMENTPursuant 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 whosupply 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==
==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 itsstatuiory 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 byindividuals 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 as t dministraive or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMAT1ION ON INDIVIDUAL OR PERSON. It is voluntaqthat you hrnmish the requested informration. including nanie. date of birth. and social security number. The social security nunber is used to assure dath NRC has an accurateidentifier not subject to the coincidence of similar names ur birth dues among the large number of petiom on whom damt is maintained. Please note. however. that thelicensee must file a termination repont containing certain required information, such a social security number. for ecdh individual whose employment or work assignment habterminated 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 maysubject the licensee to enforcement action under 10 CrR 20.601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nucear Regulatory ResearchU.S. Nuclear Regulatory Cirnmissiam.Washington. DC 20555 NRC fORM 4S US. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT14U1IS CFR J2.01S UBRSREPORT OF TERMINATING INDIVIDUALS NRC UCENSE NUMBERISIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONSOPART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDMDUAL (firs. ni6 _ u. ls*im AND ADDRESS hp0osfa)5. NAME AND ADDRESS OF EMiPOYER. IF DIFFERENT FROM ABOVE IoptDND6. SOCIAL SECURITY NUMBER M7 OATE Of I MONTH I DAY I YEARBIRTHPART II. EXTERNAL DOSE DATAS. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.la wimmf BODY WF 1{ 1 I1 EXTREMITY DOSE #mm9. PERIODISI OF EXPOSURE DEEP SHALLOW 0kng O-t dom a. TOTAL b. NEUTRON C. TOTAL d. BETA SHALLOW (skn)PART HIl. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL11.PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.IS. BIOASSAY RESULTS 17. DOSE ESTIMATES ImmI1.ITK1.EROSIOEXOUE 14. NUCLIDE 15. FORM m. IN VIVO InCil b. URINALYSIS a. COM. b.ANNUAL c. ORGAN IMKCNrsIl1ktdieht Is, II RIESULTS I LI MITTED DOSEIt) BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS-D. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REa IREMENTS OF 10 CFA 19.13. CHECK THE FOLLOWING BOX.YES Tho ,pwf is AmWud to aou wider h provwioOfl VW1 NuCkM MoguIMorI Cwmsn8ws mpbtoon 10 CFR Part 19. You WhosL ewve On mpowt tho he ference. I ar -4INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individual's Occupational ExposureIf you are licensed by the U.S. Nuclear Regulatory Commission (NRC) as specified In 120.408(a). 10 CFR Part 20. you are required to submit senrtnination radiation exposure reportson certain individuals so die Director. Office o Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is to be bken fromdose records that must be maintained under 520.401 for individuals likely to receive exposure to radiation dtt exceed a certain percentage of the NRC dose standards for die wholebody. tin or extremities-25% for workers of age IS years or more. 5% for workers younger thn IS. The tem individual" is used below to represent die worker for whom thisreport is submitted. The tern "dose" as used in Forn 439 tmd in these instructions eferst to the dose in remt as defined in 520.4ta) and subsequendy 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 de most recent terminationand was not Interupted by any previous termination during which personnel monitoring was required by 120.202(a and/or bioassays were required by your license. "Termination" isdefined in 520.3(X 19). Parts II and I1 of this form reflect regulatory requirements as well es requests intended to stahdtrdize reporting methods: requests ar clearly identified assuch.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICAllON DATAThis 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 thefollowing data:ITEM NUMBERIDte that the report was prepared.2 Current NRC license number assigned to the facility(s) in which the individual received di reported dose. If more than one license is involved, enter thelicene number for the fcility or activity under which most of the dose was incurred as he first number. If ths is ot practical. enter the license numbersin die order of original isuance.3 Name nd address of your facility as it appears on your NRC license.4 The individual's first name.- middle initial. and surname. (Address of the individuadIny be included, but hist enatered into die NRC rcords yn.5 The me and atddress of the Individual's employer. if it is different from the reporting licensee. (Optional; ot 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 DATAFor 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 dose is defined as the dose to the skin ofany past of the body. nid the extremities are defined as hands and forearms. feet and akles.item Number S If the individual was not monitored for external exposure to radiation. you are fequasux to check the box to the left nod go to Part II1.!COLUMN NUMBER9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your facility(s) pursuant to 520.202 You amre sq t to use s-nual increments us to the year of termination mid Increments not so exd e quarter for the year in which tbe individual terminated:ANNUAL: Indicate the sontdi and year of the beginning date of exposure when showing annual increments (e.g., May 1979) and Indicate the year only forubset annual increments;QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by dateCURRENT QUARTER: Specify the beginning and ending dates of die atual exposure period (month, day. year).Enter the following data:IO& Unless the eyes are shielded. enter the deep dose assessed at a tissue depth of 300 mg/cm' (lens depth) or less. If tbe eyes are prc by shielding whichhas a tissue equivalent thickness of 700 mgl/n' or mere. the deep dose may be assessed at 1000 mng/cm (gonad depth) or less. Enter the total dose orrecord. Le.. the highest dose received at the selected depth. from all types of extemal radiation saurces. at any location on the body except the akin arnd theextremities (hads t forearms. feet and ankles).lOc For all akin aeas, except that of the extremities, nter in column lOc the shallow dose Of record. tboed die ttna dose to the a I.Le.. the highest dosedelivered by al radiation incident on the skin, Including non-trivial doses from akin contamination. which penetrates to die depth at which the shallow doseIs determinied. Tbe dose at a depth of 7 mngtan' or less, averaged over I cma. is acceptable. If Column l0c is left blank. it will be assumed that the entryin lOa is applicable also for die shallow dose. Therefore. an entry for shallow dose is required only if It exceeds the deep dose.l~b h d You art tquested to enter in column l0b the contribution made by neutron radiation so the dose teported in Column lOs. atd so enter in Column l(o theontributhimiiaby beta radiation to the dose reported In Column lOc. Enter XXX if it Is known that there was so exposure to radiation of the typespecified in the column heading. Enter UNKIf a detectale exposure Is reported in lOa or lOc which could have included a beta or neutron contribution ofunknown magnhide.10 h 11 You re t ost enter m or zero (in ech column of 10. or in II) If the dose was undetectable. i.e.. te radiation to which the worker's dosimeter wase d xpw d ed sa rponse that yeu considered to be tistlly din shble from the esponse m used by herent wriabilia of the dsersystem. Note: Its sometimes required to add es (or its equivalent) to a real turmber; although NRC regulations do sot specify a sunuation procedure, dieNRC staff arbitrarily assigns 10 mrens to be a value of m (assuming 0.5 L 10 ( L where L is die detection limit) for die purposes of Statisticalanalyses.Reporting of die extremity dose is required. You are requested to comply In the following manner. Enter the dose of ecord. i.e.. the highest dose.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 tospecify dte extremity that received tbe dose. doses to different extreities should net be added together. The dose is so Include that delivered by al radsa-don Incident on the skin. including non-trivial doses from skin cnawmination, which penetntes to the depth at which the shallow dose Is determined. Thedose at a depth of 7 mg/cm5 or less is acceptable. If Column II Is let blank. it will be assumed that the entry in lOc is applicable also for the extremitydose; tm entry in Column I is required only If the shallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf you arm licensed by the NRC as specified in p0.406(a). 10 CFR Pat 20. and if your license requires bioassay services for workers at your faclity. you are required to submit ter-mination report on personnel exposures to radioactive material. containing Information that you have obtained in compliance with the license and aecorded in compliance with520.401. You wre quested ID cude in each terminstion rteport information that you have obtained in eompliance with 120.103(aX3) and 20.103(cX2) and recorded in compliancewith 120.401. This part provides for the reporting of internal monitoring procedures in terms of biotassay results. dose estimates. or hisake. Any one (or more) of these reportingmethods may be used. The term WIndividual" is used below to represent die worker for whom this report Is submitted. The term "'exposures to radioactive material" is used in cen-section with these termination reports to represent the entry of radioactive material Into the body.Item Number 12 If the individual was s t monitored for exposure to radioactive material, yOu atre u to check the box to the left: otherwise. enter the following data: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 ofmeasurements which Indicated quantities or eoncentro that 1Wcre tectable ie.. n the detction stem used. the radionudide present (if any) pro-duced a response that you considered to be statistically indistinguislhable from its background. In Column 13 enter eac year bioassay was perfoermed, 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 dotectablereults and the lower Line for those undetectable. In Ida and/or 16b: u li nter the number (including zero) of detectable measurements followed biparenthesis by the highest verified result. if any; lower line. enter thme (including zero) of measurements indicatdng sndetectable amount C IYNSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 (Continued; Column 13 Column 14 Column 13 Column 16l6all) 16f21 l6b (pCUL1932 U-nat 1 0 lung VI)2 lung 1o1983 U-natth 2341 I 1..7 lung 4(61Ilung S1934 U-nat(Th 2341 1 2(14 lung 12(13)0 lung 0Units for die numbers in parentheses shown in Column 16b are to be specified in the heading for Column 16b. If Columns 17 or IS are conmplted. nota-tions in Column 16 are unnecessary.If the dose commitment 150-year integrated dose) is reported. indicate in Column 13 by beginning and ending dares (month. day. year) td period duringwhich tde associated radioactive material was taken into te body.If annual doses are reported. enter in Column 13 tde calendar year over which each dose was integrated. including the first and any succeeding yearn ofthis employment or work assignmernt and the year following the termination date.For entries in Column 18 (intake;. specify the reporting intervals (periods of exposure) during which die individual was exposed to concentrations ofradioactive material. using annual increments up to the year of termination and increments not to exceed.one quarter for the year in which die individualterminated. The periods of exposure for intake& should appear as follows:ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e.g.. June 1983) and indicate tie year only forsubsequent annual increments.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 urinalysismeasurements were performed (e.g.. Co 60. U 235;. If the measured quantity of activity for one radionudida is alao used to essimate other radionuclidtquantities identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See die example gives ia thedirections for Column 13 where U-nat(Th 234; is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tl234 photons.is Enter the form. S for soluble or I for insoluble. of the radionuclide to which tie worker was exposed. if unknown. use quoes around the letter. thus in-dicating which concentration value in Part 20. Appendix B. Table 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 or ie. Youmay use one or more of these methods.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 detectablemeasurements followed by the highest verified result (in nanocuries; In parentheses. On the next line is this column. enter the number of meatiremenUs thatindicated undetectable amounts. Specify in Column 16c(21 the organ in which the indicated radionuclide was found. See the example given in dte direction.for Column 13.16b Firm enter the grnvimetric or radionetrik unit in which the urinalysis results are reported (eg.. micrograms per liter. nanocuries per Iter) is the blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the numiber of detectable resultsfollowed 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 tdenext line in this column. enser the number of measurements indicating 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 in Column 17a or 17b. (Note thdt it is not necessary to provide both the committedand annual doses.; For Columns 17a and 17b you amr requested to follow the procedures below: if any alternative procedures ae used. describe themn onsthe back of this forta. In 17a. enter the dose integrated from t to 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 or work assignmentand the yer following the termination date. Base dose estimates on the quantity fa a minimum; of the radionuclide, Column 14. taken into the body atyour facility(sl during this employment or work-assignment period.IS Reporting of radionuclide intakes. as determined by air sampling. is not required by 10 CFR 20.401. However. should this option be chosea indicate thetime-weighted concentrations of radioactive material (i.e.. MPC-hoursn to which the individual was exposed during the time perioda indicated in Column 13.Refer to te 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 ColumnItem 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 STATEMENTPursuant 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 to individuals and personn whosupply informatio so the Nuclear Regulatory Commission on NRC Form 439. This information Ls maintained in a system of records designated as NRC-27 and described at 40Federal Register 45344 (October 1. 1975).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. 2073. 2093. 2095. 2111. 2133. 2134.2201fb;. and 22014o);. The authority for soliciting the social security number is 10 CFR Parn 20.2. PRINCIPAL  
(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 itsstatuiory 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 byindividuals 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 as t dministraive or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMAT1ION ON INDIVIDUAL OR PERSON. It is voluntaqthat you hrnmish the requested informration. including nanie. date of birth. and social security number. The social security nunber is used to assure dath NRC has an accurateidentifier not subject to the coincidence of similar names ur birth dues among the large number of petiom on whom damt is maintained. Please note. however. that thelicensee must file a termination repont containing certain required information, such a social security number. for ecdh individual whose employment or work assignment habterminated 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 maysubject the licensee to enforcement action under 10 CrR 20.601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nucear Regulatory ResearchU.S. Nuclear Regulatory Cirnmissiam.Washington. DC 20555 NRC fORM 4S US. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT14U1IS CFR J2.01S UBRSREPORT OF TERMINATING INDIVIDUALS NRC UCENSE NUMBERISIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONSOPART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDMDUAL (firs. ni6 _ u. ls*im AND ADDRESS hp0osfa)5. NAME AND ADDRESS OF EMiPOYER. IF DIFFERENT FROM ABOVE IoptDND6. SOCIAL SECURITY NUMBER M7 OATE Of I MONTH I DAY I YEARBIRTHPART II. EXTERNAL DOSE DATAS. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.la wimmf BODY WF 1{ 1 I1 EXTREMITY DOSE #mm9. PERIODISI OF EXPOSURE DEEP SHALLOW 0kng O-t dom a. TOTAL b. NEUTRON C. TOTAL d. BETA SHALLOW (skn)PART HIl. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL11.PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.IS. BIOASSAY RESULTS 17. DOSE ESTIMATES ImmI1.ITK1.EROSIOEXOUE 14. NUCLIDE 15. FORM m. IN VIVO InCil b. URINALYSIS a. COM. b.ANNUAL c. ORGAN IMKCNrsIl1ktdieht Is, II RIESULTS I LI MITTED DOSEIt) BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS-D. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REa IREMENTS OF 10 CFA 19.13. CHECK THE FOLLOWING BOX.YES Tho ,pwf is AmWud to aou wider h provwioOfl VW1 NuCkM MoguIMorI Cwmsn8ws mpbtoon 10 CFR Part 19. You WhosL ewve On mpowt tho he ference. I  
ar -4INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individual's Occupational ExposureIf you are licensed by the U.S. Nuclear Regulatory Commission (NRC) as specified In 120.408(a). 10 CFR Part 20. you are required to submit senrtnination radiation exposure reportson certain individuals so die Director. Office o Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is to be bken fromdose records that must be maintained under 520.401 for individuals likely to receive exposure to radiation dtt exceed a certain percentage of the NRC dose standards for die wholebody. tin or extremities-25% for workers of age IS years or more. 5% for workers younger thn IS. The tem individual" is used below to represent die worker for whom thisreport is submitted. The tern "dose" as used in Forn 439 tmd in these instructions eferst to the dose in remt as defined in 520.4ta) and subsequendy 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 de most recent terminationand was not Interupted by any previous termination during which personnel monitoring was required by 120.202(a and/or bioassays were required by your license. "Termination" isdefined in 520.3(X 19). Parts II and I1 of this form reflect regulatory requirements as well es requests intended to stahdtrdize reporting methods: requests ar clearly identified assuch.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICAllON DATAThis 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 thefollowing data:ITEM NUMBERIDte that the report was prepared.2 Current NRC license number assigned to the facility(s) in which the individual received di reported dose. If more than one license is involved, enter thelicene number for the fcility or activity under which most of the dose was incurred as he first number. If ths is ot practical. enter the license numbersin die order of original isuance.3 Name nd address of your facility as it appears on your NRC license.4 The individual's first name.- middle initial. and surname. (Address of the individuadIny be included, but hist enatered into die NRC rcords yn.5 The me and atddress of the Individual's employer. if it is different from the reporting licensee. (Optional; ot 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 DATAFor 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 dose is defined as the dose to the skin ofany past of the body. nid the extremities are defined as hands and forearms. feet and akles.item Number S If the individual was not monitored for external exposure to radiation. you are fequasux to check the box to the left nod go to Part II1.!COLUMN NUMBER9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your facility(s) pursuant to 520.202 You amre sq t to use s-nual increments us to the year of termination mid Increments not so exd e quarter for the year in which tbe individual terminated:ANNUAL: Indicate the sontdi and year of the beginning date of exposure when showing annual increments (e.g., May 1979) and Indicate the year only forubset annual increments;QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by dateCURRENT QUARTER: Specify the beginning and ending dates of die atual exposure period (month, day. year).Enter the following data:IO& Unless the eyes are shielded. enter the deep dose assessed at a tissue depth of 300 mg/cm' (lens depth) or less. If tbe eyes are prc by shielding whichhas a tissue equivalent thickness of 700 mgl/n' or mere. the deep dose may be assessed at 1000 mng/cm (gonad depth) or less. Enter the total dose orrecord. Le.. the highest dose received at the selected depth. from all types of extemal radiation saurces. at any location on the body except the akin arnd theextremities (hads t forearms. feet and ankles).lOc For all akin aeas, except that of the extremities, nter in column lOc the shallow dose Of record. tboed die ttna dose to the a I.Le.. the highest dosedelivered by al radiation incident on the skin, Including non-trivial doses from akin contamination. which penetrates to die depth at which the shallow doseIs determinied. Tbe dose at a depth of 7 mngtan' or less, averaged over I cma. is acceptable. If Column l0c is left blank. it will be assumed that the entryin lOa is applicable also for die shallow dose. Therefore. an entry for shallow dose is required only if It exceeds the deep dose.l~b h d You art tquested to enter in column l0b the contribution made by neutron radiation so the dose teported in Column lOs. atd so enter in Column l(o theontributhimiiaby beta radiation to the dose reported In Column lOc. Enter XXX if it Is known that there was so exposure to radiation of the typespecified in the column heading. Enter UNKIf a detectale exposure Is reported in lOa or lOc which could have included a beta or neutron contribution ofunknown magnhide.10 h 11 You re t ost enter m or zero (in ech column of 10. or in II) If the dose was undetectable. i.e.. te radiation to which the worker's dosimeter wase d xpw d ed sa rponse that yeu considered to be tistlly din shble from the esponse m used by herent wriabilia of the dsersystem. Note: Its sometimes required to add es (or its equivalent) to a real turmber; although NRC regulations do sot specify a sunuation procedure, dieNRC staff arbitrarily assigns 10 mrens to be a value of m (assuming 0.5 L 10 ( L where L is die detection limit) for die purposes of Statisticalanalyses.Reporting of die extremity dose is required. You are requested to comply In the following manner. Enter the dose of ecord. i.e.. the highest dose.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 tospecify dte extremity that received tbe dose. doses to different extreities should net be added together. The dose is so Include that delivered by al radsa-don Incident on the skin. including non-trivial doses from skin cnawmination, which penetntes to the depth at which the shallow dose Is determined. Thedose at a depth of 7 mg/cm5 or less is acceptable. If Column II Is let blank. it will be assumed that the entry in lOc is applicable also for the extremitydose; tm entry in Column I is required only If the shallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf you arm licensed by the NRC as specified in p0.406(a). 10 CFR Pat 20. and if your license requires bioassay services for workers at your faclity. you are required to submit ter-mination report on personnel exposures to radioactive material. containing Information that you have obtained in compliance with the license and aecorded in compliance with520.401. You wre quested ID cude in each terminstion rteport information that you have obtained in eompliance with 120.103(aX3) and 20.103(cX2) and recorded in compliancewith 120.401. This part provides for the reporting of internal monitoring procedures in terms of biotassay results. dose estimates. or hisake. Any one (or more) of these reportingmethods may be used. The term WIndividual" is used below to represent die worker for whom this report Is submitted. The term "'exposures to radioactive material" is used in cen-section with these termination reports to represent the entry of radioactive material Into the body.Item Number 12 If the individual was s t monitored for exposure to radioactive material, yOu atre u to check the box to the left: otherwise. enter the following data: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 ofmeasurements which Indicated quantities or eoncentro that 1Wcre tectable ie.. n the detction stem used. the radionudide present (if any) pro-duced a response that you considered to be statistically indistinguislhable from its background. In Column 13 enter eac year bioassay was perfoermed, 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 dotectablereults and the lower Line for those undetectable. In Ida and/or 16b: u li nter the number (including zero) of detectable measurements followed biparenthesis by the highest verified result. if any; lower line. enter thme (including zero) of measurements indicatdng sndetectable amounts.
 
C IYNSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 (Continued; Column 13 Column 14 Column 13 Column 16l6all) 16f21 l6b (pCUL1932 U-nat 1 0 lung VI)2 lung 1o1983 U-natth 2341 I 1..7 lung 4(61Ilung S1934 U-nat(Th 2341 1 2(14 lung 12(13)0 lung 0Units for die numbers in parentheses shown in Column 16b are to be specified in the heading for Column 16b. If Columns 17 or IS are conmplted. nota-tions in Column 16 are unnecessary.If the dose commitment 150-year integrated dose) is reported. indicate in Column 13 by beginning and ending dares (month. day. year) td period duringwhich tde associated radioactive material was taken into te body.If annual doses are reported. enter in Column 13 tde calendar year over which each dose was integrated. including the first and any succeeding yearn ofthis employment or work assignmernt and the year following the termination date.For entries in Column 18 (intake;. specify the reporting intervals (periods of exposure) during which die individual was exposed to concentrations ofradioactive material. using annual increments up to the year of termination and increments not to exceed.one quarter for the year in which die individualterminated. The periods of exposure for intake& should appear as follows:ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e.g.. June 1983) and indicate tie year only forsubsequent annual increments.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 urinalysismeasurements were performed (e.g.. Co 60. U 235;. If the measured quantity of activity for one radionudida is alao used to essimate other radionuclidtquantities identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See die example gives ia thedirections for Column 13 where U-nat(Th 234; is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tl234 photons.is Enter the form. S for soluble or I for insoluble. of the radionuclide to which tie worker was exposed. if unknown. use quoes around the letter. thus in-dicating which concentration value in Part 20. Appendix B. Table 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 or ie. Youmay use one or more of these methods.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 detectablemeasurements followed by the highest verified result (in nanocuries; In parentheses. On the next line is this column. enter the number of meatiremenUs thatindicated undetectable amounts. Specify in Column 16c(21 the organ in which the indicated radionuclide was found. See the example given in dte direction.for Column 13.16b Firm enter the grnvimetric or radionetrik unit in which the urinalysis results are reported (eg.. micrograms per liter. nanocuries per Iter) is the blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the numiber of detectable resultsfollowed 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 tdenext line in this column. enser the number of measurements indicating 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 in Column 17a or 17b. (Note thdt it is not necessary to provide both the committedand annual doses.; For Columns 17a and 17b you amr requested to follow the procedures below: if any alternative procedures ae used. describe themn onsthe back of this forta. In 17a. enter the dose integrated from t to 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 or work assignmentand the yer following the termination date. Base dose estimates on the quantity fa a minimum; of the radionuclide, Column 14. taken into the body atyour facility(sl during this employment or work-assignment period.IS Reporting of radionuclide intakes. as determined by air sampling. is not required by 10 CFR 20.401. However. should this option be chosea indicate thetime-weighted concentrations of radioactive material (i.e.. MPC-hoursn to which the individual was exposed during the time perioda indicated in Column 13.Refer to te 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 ColumnItem 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 STATEMENTPursuant 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 to individuals and personn whosupply informatio so the Nuclear Regulatory Commission on NRC Form 439. This information Ls maintained in a system of records designated as NRC-27 and described at 40Federal Register 45344 (October 1. 1975).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. 2073. 2093. 2095. 2111. 2133. 2134.2201fb;. and 22014o);. The authority for soliciting the social security number is 10 CFR Parn 20.2. PRINCIPAL  


==PURPOSE==
==PURPOSE==
(S). The information is used by the NRC in its evaluatipn of the risk of radiation exposure associatedwibh the licensed activity and in exercising itsstatutory responsibility to monitor and regulate the safety and health practices of its licensees. The dat permit a metninghi comprison of both current and long-tern ex-posure experience among types of licenees and among licensees within each type. Data on your exposure to radiation ar avaible to you upot t request3. ROUTINE USES. The information mny be used lo provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation expoture received byindividuals employed as radiation workers on a penranent or temporary basis and exposure received by monitored visitors. The information may alto be disclosed to an ap-propriae Federal. State. or local agency in te event the information indicates a violation or potential violation of law and in the course of an adinini v or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested infornation. including name. date of birth. and social security number. The social security number is used to assure that NRC has an accurateidentifier not subject to the coincidence or similar names or birth dates among the large number of persons on whom data is maintaied. Please note. however. that thelicensee rmost file termination report containing certain required information. such as social security number. for each individual whose employment or work assignment haterminated and for whom personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR l20.202 and 20.408 maysubject the licensee to enforcement action under 10 CFR 20Q601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Offi e of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissitnWashingt. DC 20555 jLIST OF RECENTLY ISSUED GENERIC LETTERSGENERICLETTER NO. SUBJECT DATE84-20 Scheduling Guidance for Licensee Submittalsof Reloads that Involve Unreviewed SafetyQuestions 8/20/8484-21 Long Term Low Power Operation in PWR's 10/16/8484-22 Not used84-23 Reactor Vessel Water Level Instrumentationin BWRs 10/26/8484-24 Clarification of Compliance to 10 CFR 50.49Environmental Qualification of ElectricalEquipment Important to Safety for NuclearPower Plants 12/27/8485-01 Fire Protection Policy Steering CommitteeReport 1/9/8585-02 Staff Recommended Actions Stemming From NRCIntegrated Program for the Resolution ofUnresolved Safety Issues Regarding SteamGenerator Tube Integrity 4/15/8585-03 Clarification of Equivalent Control Capacity 1/28/85For Standby Liquid Control Systems85-04 Operator Licensing Examinations 1/29/8585-05 Inadvertent Boron Dilution Events 1/31/8585-06 Quality Assurance Guidance for ATWSEquipment that is not Safety-Related 4/16/8585-07 Implementation of Integrated Schedules 5/02/85for Plant Modifications85-08 10 CFR 20.408 Termination Reports -Format 5/23/8585-09 Technical Specifications for GenericLetter 83-28, Item 4.3 5/23/8585-10 Technical Specifications for GenericLetter 83-28, Items 4.3 and 4.4 5/23/85}}
(S). The information is used by the NRC in its evaluatipn of the risk of radiation exposure associatedwibh the licensed activity and in exercising itsstatutory responsibility to monitor and regulate the safety and health practices of its licensees. The dat permit a metninghi comprison of both current and long-tern ex-posure experience among types of licenees and among licensees within each type. Data on your exposure to radiation ar avaible to you upot t request3. ROUTINE USES. The information mny be used lo provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation expoture received byindividuals employed as radiation workers on a penranent or temporary basis and exposure received by monitored visitors. The information may alto be disclosed to an ap-propriae Federal. State. or local agency in te event the information indicates a violation or potential violation of law and in the course of an adinini v or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested infornation. including name. date of birth. and social security number. The social security number is used to assure that NRC has an accurateidentifier not subject to the coincidence or similar names or birth dates among the large number of persons on whom data is maintaied. Please note. however. that thelicensee rmost file termination report containing certain required information. such as social security number. for each individual whose employment or work assignment haterminated and for whom personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR l20.202 and 20.408 maysubject the licensee to enforcement action under 10 CFR 20Q601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Offi e of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissitnWashingt. DC 20555 jLIST OF RECENTLY ISSUED GENERIC LETTERSGENERICLETTER NO. SUBJECT DATE84-20 Scheduling Guidance for Licensee Submittalsof Reloads that Involve Unreviewed SafetyQuestions 8/20/8484-21 Long Term Low Power Operation in PWR's 10/16/8484-22 Not used84-23 Reactor Vessel Water Level Instrumentationin BWRs 10/26/8484-24 Clarification of Compliance to 10 CFR 50.49Environmental Qualification of ElectricalEquipment Important to Safety for NuclearPower Plants 12/27/8485-01 Fire Protection Policy Steering CommitteeReport 1/9/8585-02 Staff Recommended Actions Stemming From NRCIntegrated Program for the Resolution ofUnresolved Safety Issues Regarding SteamGenerator Tube Integrity 4/15/8585-03 Clarification of Equivalent Control Capacity 1/28/85For Standby Liquid Control Systems85-04 Operator Licensing Examinations 1/29/8585-05 Inadvertent Boron Dilution Events 1/31/8585-06 Quality Assurance Guidance for ATWSEquipment that is not Safety-Related 4/16/8585-07 Implementation of Integrated Schedules 5/02/85for Plant Modifications85-08 10 CFR 20.408 Termination Reports -Format 5/23/8585-09 Technical Specifications for GenericLetter 83-28, Item 4.3 5/23/8585-10 Technical Specifications for GenericLetter 83-28, Items 4.3 and 4.4 5/23/85  
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Revision as of 19:05, 6 April 2018

NRC Generic Letter 1985-008: 10 CFR 20.408 Termination Reports - Format
ML031150676
Person / Time
Site: Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date: 05/23/1985
From: Thompson H L
Office of Nuclear Reactor Regulation
To:
References
-RFPFR GL-85-008, NUDOCS 8505210106
Download: ML031150676 (19)
v • d • e


TO ALL HOLDERS OF CONSTRUCTION PERMITS AND OPERATING LICENSESSUBJECT: 10 CFR 20.408 TERMINATION REPORTS -FORMATGENERIC LETTER NO. 85-08Pursuant to 10 CFR 20.408, licensees are required to submit to the NRC areport of each individual's exposure to radiation and radioactive materialwhen the individual terminates employment or work assignment at theirfacility. These exposure reports are commonly referred to as §20.408termination reports.Previously, we have not specified a preferred reporting format for compliancewith this regulation. However, the NRC is currently receiving approximately100,000 termination reports each year, and this number is steadily increasing.For purposes of efficient automatic data processing, it is important to use astandard format. Processing in a more timely fashion will make the data moreuseful to the NRC and others in their performance of various duties (seeEnclosure 1).For future §20.408 termination reports we request that you voluntarily use theattached Standard NRC Form-439. Instructions for completing the form are attachedto the form. Questions regarding these instructions should be directed to BarbaraG. Brooks, Office of Nuclear Regulatory Research, Washington, D. C. 20555,(301) 427-4577.The NRC is also conducting a pilot program for the electronic transmissionof the termination data to the NRC via computer tapes or by direct linkup tothe NRC's computing facility, and we would like to encourage you to considerparticipating. Should you desire more information about this program pleasecontact Ms. Brooks.The form is intended for use in connection with the information collectionrequirement established in Section 20.408, 10 CFR Part 20 and approved underOMB Clearance Number 3150-0014.ompson, JN*, Dir oro viion of Licensfng /g1/O ce of Nuclear Reactot egulationEnclosure:1.Ues-of Radiation Exposure Data I2. Five copies of NRC Form 439c i L ttflenercilel;1ers -g>8505210106PDQI A-DOCK O 500L

Uses of Radiation Exposure DataA number of NRC licensees have inquired as to how occupational-radiationexposure data (from reports required by the NRC)'are used by the NRC staff.This is a very appropriate inquiry that may be of importance' to many affectedlicensees. In combination with other sources of information, the principalVW uses of the data are to provide facts regarding routine occupationalexposures to radiation and radioactive material that occur in connection withNRC-licensed activities, including individual and collective radiation dosesfrom external sources as well as pertinent information on the inhalation ofradioactive material (nuclides involved, bioassay results, exposure magnitude,etc.) These facts are used by the NRC staff as indicated below:1. The external-dose data permit evaluation of the'radiological riskassociated with NRC-licensed activities, including the size of theworkforce and the collective dose.2. The data permit evaluation, from the viewpoint'of trends, of theeffectiveness of the overall NRC/licensee radiation protection and ALARAefforts. They also provide for the identification (and subsequentcorrection) of unfavorable trends.3. The data provide for governmental monitoring of the potential transient-worker problem.4. The data are used in the establishment of priorities for the utilizationof NRC health physics resources: research, standards development,regulatory program development.5. The data are considered in reviews of inspection frequencies that areprogrammed 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 protectionperformance: US/foreign, BWR's/PWR's, civilian/military, plant by plant,nuclear industry with other industries, etc.8. The data permit analysis of annual dose distribution changes which cantrigger investigations as to the cause.9. The data are used for purposes of justification in the annual budgetprocess.10. The data provide facts for evaluating the adequacy of the currentrisk-limitation system (e.g., are individual lifetime dose limits, workerpopulation 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 thecollective dose).12. The data provide facts for answering Congressional and Administrationinquiries and for responding to questions raised by public interestgroups, special interest groups, labor unions, etc.13. The data permit comparisons of occupational radiation risks withpotential public risks when action for additional protection of thepublic involves worker exposures.14. The data provide information which can be used in the planning ofepidemiological studies.-With regard to routine work-place conditions, the annual statistical summaryreports required by 20.407, the termination reports required by §20.408, andthe annual dose data reported by work function in accordance with Subsection6.9.1.5 of the standard technical specifications for nuclear power plantsprovide the only centralized data base available to assist the staff in theperformance of its duties as listed above. It is to everyone's advantage ifthese duties are performed by a well-informed staff in the light of factualinformation.2 NRC FORM 419 U.S. NUCLEAR REGULATORY COMMISSION I- DATE Of REPORT10 CFR im0 401REPORT OF TERMINATING INDIVIDUAL'S 2 NRC UCENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDM4DUAL flet. wmd k"a lest) AND ADDRESS WtionafiB. NAME AND ADDRESS OF EMPLOYER. IF OIFFERENT FROM ABOVE 1tonafl.SOCIAL SECURITY NUMBER l a DATE OF I MONTHI DAY I YEARm BIRTHPART 11. EXTERNAL DOSE DATA18 PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI OF EXPOSURE DEEP WHOSHALLOW Iskint It K Im REMITY OMteerlust date Am)t TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW bk~mfPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.18. BIOASSAY RESULTS 17. DOSE ESTIMATES 1rms)13. PERIODISI OF EXPOSURE 13. INTAKEAiate Alt 14 U NUCLIDE 15. FORM a.IN VIVO InCil It. URINALYSIS a. COM b. ANNUAL c. ORGAN IMPC-Hre.1fefetis.,I RESULTS I Li MITTED DOSEIlI BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.YES (Thi report 6 Awrnd to vou uider the provaion of Ite Nucfu RepuYtwy Commdersua regulatmon 10 CFR Pert 19. Yu should Prserv rho report far fue mrefrmce INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating individual's Occupational ExposureIf 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 exposure reportson eetain individuals to the Director. Oflice of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is so be taken fromdose 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 standards for die wholebody, 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 thisreport 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 "dose equivalent"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 terminationand 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. "Termination" isdefined in 120 3(X 19). Pans 1 and MI of this form reflect regulatory requirements as well as requests intended to standardize reporting methods, requests are clearly identified assuch.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 applicable. Enter thefowing data:ITEM NUMBERDate 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 thelicense 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 numbersin 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 DATAFor the purpose of this form. the deep dose is defined as the dose tasesed at tissue depth of 300 or 1.000 mg/cm' (or less). the shallow dose is defined as the dose to the sin ofany 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 VGUJIvwrJE9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your ficility(s) pursuant to 520202 You are requeted to use an-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 forsubsequent annual Increments.QUARTER: For each eompleted qlarter or bhe 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);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 whichhas 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 ofrecord 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 theextremities (hands and forearms feet and ankles).IOc For anl skin 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 dosedelivered by all radiation Incident on the skin, icluding non-trivial doses from skin contamination, which petates to the depth at which the shallow doseis 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 entryin 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 theeoetributw1iin&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 typespecified 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 ofunknown 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 wasexoed peuda response that you considered to be statistically indistinguishable from the response cae by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or Its equivalent) to a teal number; although NRC regulations do not speciy a summation procedure. theNRC 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 statisticalandyses.-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 tospeciy 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 is determined. hedose at depth of 7 mgfcm5 or less ih acceptable. If Column II is lft blank. it will be assumed that the entry in l0c is applicable also for the extremitydose; an entry in Column II is required only if the hiallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 required to submit ter-mination reports on personnel exposures to radioactive material. contaning information that you have obtained In compliance with the license and' recorded in compliance withV20.401. 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 in compliancewith 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) of the reportingmethods may be ued. The term "individual" is used below to represent the worker for whom this report is submitted. The term "exposures to radioactive material" is used in con-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 ormeasurements 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: spprline. enter the number (including ero) of detectable measurements followed inparenthesis 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 (ContinuedlCOLUMN NUMBER13 WContinuedl Column 13 Column 14 Column 1 Coluhnm 1616a(1l 1621 Itib (pCUL)1932 U-nat 1 0 luns 2l)2 lung 1019S3 U-nat(Th 2341 1 It71 luns 4(61I lung S19S4 U-nat(Th 2341 1 21141 lung 124310 lung 0Units 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 arm unnecessary.If the dose commitment 150-year integrated dosel is reported. indicate in Column 13 by beginning and ending dates (month, day. year) the period duringwhich 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 ofthis 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 ofradioactive material. using annual increments up to the year of termination and increments not to exceed one quarter for te year in which the individualterminated. 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 forsubsequent 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 urinalysismeasuremtents were performed (e.g.. Co 6D. U 2351. If the measured quantity of activity for one radionuclide is also used to estimage other radionuclidequantities. identify the radionuclide actually measured in parentheses immediately slter die radimonuclide listed in Coluns 14. See the example given is thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tn234 phoon=s15 Enter die fonts. S for soluble or I for insoluble. of die radionuclide to which the worker was exposed. If unknown. use quotes around the leter thus indicating which concentration value in Part 20. Appendix S. Table 1. Columa I. was assumed 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. Youmay 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.a41 the number of detectablemeasurements followed by the highest verified result (in nancocuries) in parentheses. On the next line in this column. enter the number of measurements thatindicated undetectable amounts. Specify in Column 16.2) the organ in which the indicated radionuclide was found. Se the example given in the directionsfor Column 13.16b First. enter the gravimetric or radiometric unit in which the urinalysis results are reported te.g.. micrograms per liter. nanocuries per liter) in the blankspace of the heading for Column 16b. Is Column 16b. for each year during which urinalyses were performed. enter die number of detectable resultfollowed 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 thenext 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 commnittedand annual doses.) For Columns 17a and 17b you ar requested to follow dut procedures below: if ay alternative procedures are used, describe the.n ondie 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 assignmentand the year following tde termination date. Base dose estimates on the quantity las a minimuni of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column1l.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 ataisfy the notification requirement of 10 CFR 19.13. check the "Yes" box.PRIVACY ACT STATEMENTPursuant 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 whosupply information to the Nuclear Regulatory Commission on NRC Form 439. This information is maintatined in a system of records designated as NRC-27 and described at 40Federal 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 itsstatutory 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 request3. 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarydot 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 accurateidentifier 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 thelicease must file a termination report containing tertain required information, such as social security number. for each individual wvhos employmnent or work assignment hasterminated and for whomt personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the informatdon under 10 CFl 120.202 and 20.403 maysubject the licensee to enforcement action under 10 CFl 20.601.S. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CotmmiminWaishingt. DC 20555 NRC FORM 41 U.S. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT10 CFR _20.4__REPORT OF TERMINATING INDIVIDUALS 2. NRC UQCENSE NUMBER4SIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. 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 1006onafl6. SOCIAL SECURITY NUMBER I MONTH I DAY I YEAR7. DATE OFB IRTHPART II. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.9. PERIODISI Of EXPOSURE DEEP 10 WHOLE BODY SHALLFW t i. EXTEMITY DOSE Anda. TOt

  • s i OTAL b. NEUTRON c. TOTAL d. BETA SHALLOWPART III. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALl12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tmot13. PERIDDISI OF EXPOSURE lB. INTAKE1.PRIOD dt fEPU U. NUCLIDE 15 FORM a. IN VIVO InMC b. URINALYSIS S. COM- b.ANNUAL c. ORGAN IMPC NHr.lIs. II -ESULTS I LI MITTED DOSEI. BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS20. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION 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 ExposureIf 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 reportson certain individuals to the Director, Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Comnmission. Washington. DC 20555. This information is to be taken fromdose 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 wholebody. 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 thisreport 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 terminationand 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" isdefined in 520.3(a)(19). Parts 1 and 11l of this form reflect regulatory requiremnents as well as requests intended to standardize reporting methods- requests re clearly identified assuch.PART 1 LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin the order of original issuance3 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.I5 The name and 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 DATAFor 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 so the skin ofany 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 So check the box to the left nd go to Part 11.COLUMN NUMBER9 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 fort 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin, including non-trivial doses from skin contamination. which penetrates to the depth at which the shallow doseis 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 entryin 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 theeontribution 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 typespecified 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 ofuvknown 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 wasexposed pic a response tdat you considered to be statistically indistinguishable from dte response cused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add m (or its equivalent) to a real number, although NRC regulations do sot specify a summation procedure. theNRC 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 statisticalanalyses.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 and ankles during the reported period. It is unnecessary Iospecify 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 ia determined. Thedose 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 fan entry in Cohumn II is required only if the shallow dose exceeded the deep dose.PART I. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 compliancewith 120.401. This part provides for due reporting of internal monitoring procedures in tenns of bioassay results, dose estimates, or intake. Any one (or more) of these reportingmethods 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 ofmasufletnents 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b: pper line. enter the number (including Mero) of detectable Measurenients followed inparenthesis 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 (ContiICOLUMN NUMBER13 (Continued) Column 13 Column 14 Column 15 Column 1616d l l 166l21 lt~b (pCit1982 U-nat 1 0 lung 2(1-2 lung 1019S3 U-nattTh 2341 2 lC? lung 4463I lung S1984 U-natfih 234 1 2041 lung 1241330 lung 0Units 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. notations 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 duringwhich 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 ofthis~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 ofradioactive material, using annual increments up to die yea of termination and increments not to exceed one quarter for the year in which the individualterminated. 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 forsubsequent 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 urinalysimeasurements were performed (e.g.. Co 60. U 2353. If the measured quantity of activity for one radionuclide is also used to estimate other radionuclidequantities. identify die radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2342 is entered in Column 14 indicating that the uranium lung burden was determined fron measurements ofTh234 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. Youmay 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 detectablemeasurements followed by the highest verified result (in nanocuriesi in parentheses. On the next line in this column, enter the number of measurements thatindicated undetectable amounts. Specify in Column 16at2) the organ in which the indicated radionuclide was found. See the example gives in tde directionsfor 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 blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the number of detectable resultsfollowed 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 thenext 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 committedand annual doses.) For Columns I7b and 17b you we requested to follow the procedures below: if any alternative procedures are used, describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (as a minimum) of the radionuclide. Column 14. taken into the body atyour facilityts) during ;his employment or work-assignment period.IS Reporting of radionuclide intakesa as determined by sir sampling, is not required by 10 CFR 20408. However, should thia option be chosen, indicate thetime-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 Columnla.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 STATEMENTPtruant 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 whosupply 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 40Federal 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 itsstatutory 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 byindividuals employed as radiation workers on a permanent or temporary bass and exposure received by monitored visitors. The Wormatio may also be disclosed to an appirops 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. k is voluntarythat 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 accurateidentifier 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 thelicemiee must file a termination report containing certain required information, such as social security number, for each individual whose employment or work assignment hasterminated 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 maysubject the licensee to enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERLS3 AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissiinWashington. DC 20555 NRC FORM U.S. NUCLEAR REGULATORY COMMISSION I. TOF REPORT10 CMR p0.411REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUMBERIS)OCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA2. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDIVIDUAL tMMt. mte hmdli est) AND ADDRESS boItorlS. NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE IO(tlnallt. SOCIAL SECURITY NUMBER M7. DATE OF I ONTH I DAY I YEARI BIRTHPART 11. EXTERNAL DOSE DATA18. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED._ 9. PERODS OF EXPOSURE DEEP 10 WHOLE BODY D ALWt )I I. EXTREMITY DOSE froml3.PRoCsI Of dEXPoSUElE SHALLOW take,)a. TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW tintPART Ill. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL_12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.16. BIOASSAY RESULTS 17. DOSE ESTIMATES tnml13. PERIOCISI OF EXPOSURE 14. NUCUADE IS FORO IO. INTAKEVeretdpte A A.NULDE 16 FR a. IN VIVO InCiI b. URINALYSIS S. COM- b. ANNUAL c. ORGAN 4MPC.HrsIis. II RESULTS I LI MITTED DOSEIll BURDEN t21 ORGAN DOSE19. OTHER BIOASSAY RESULTS0. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REOUIREMENTS OF tO CR 19.13. CHECK THE FOLLOWING BOX.YES IThise m fian ted to VW rw lew povmion of VWe NdlRoar ltovy CG m 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 ExposureIf 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 reportson certain individuals to the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regubatosy Commission. Washington. DC 20555. This infornation is to be taken fromdose 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 wholebody, 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 thisrepor 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 ternninationaid 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" isdefined in 120.3tXt19). Parts U and 11l of this form reflect regulatory requirements as well as requests intended to standardize reporting methods: requests are dearly identified assuch.PART I LICENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 dhe skin ofany 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 NUMBER9 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 noo to 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 forbsequent 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 whichhas 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 ofrecord. 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 theextremities (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 dosedelivered by all radiation incident on the skin. including non-trivial doses from Skin contamionaion, which penettes to the depth at which the shallow doseis determirne. The dose st a depth of 7 mgeimn or less, averaged over I cm'. is acceptasle. If Column Ilk is left blank. it will be assumed that the entryin 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, mnd to enter in Column l0d theeontributiiinudeby beta radiation to the dose reported in Column lOc. Enter XXX if it is known that there was no exposure to radiation of the typespecified 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 Ofunknown magniude.10 & 11 You re r bt enter mn or zao (in each colurnr of 10. or in II) if the dose was undetectable. ie.. the radiation to which the worker's dosimeter wasexposed produc a response that you considered to be statistically indistinguishable from dhe response esused by inherent varibilities o the dosmetersystem. Note It is sometmcs required to add m (or its equivalent) to a real number; although NRC regulations do nut specify a summation procedure. theNRC 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 statisticalanalyses.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 hMnds and foreans or feet tad ankles during the reported period. It is unnecessary tospecify 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 dete rmined. Thedose 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 extremitydose; a ensy in Column II is required only if the shallow dos exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The term "individual" is used below to represent hie worker hor whom 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 nto monitored 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 ofmeasurements which indicated quantities or concenurationsV were 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 detectableresults and the lower line for those undetectable. In 16a and/or 16b : Iine enter dhe number (including zero) of detectable measurements followed inparenthesis 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 NUMBER13 iContinuled Column 13 Column 14 Column IS Column 1616aglI 16t421 16b (IpClL.19J2 U-nat 1 0 lung 2(232 lung 101913 U-nat(Th 2343 ..I. 1t71 lung 4(61I lung a1984 U-natth 2343 ..I. 2tl41 lung 121330 lung 0Units orr the 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 duringwhich 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 ofthis 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 ofradioactive material. using annual incremnts up to the year of termination and increments not to exceed one quarter for the year in which the individualterminated. The periods of exposure for intakes should appear as follows:ANNUAL: Indicate doe monds and year of the beginning date of exposure when showing annual incremtents (e.g.. June 923) ;and indicate the year only forsubsequent annual increments.QUARTER: For each completed quarter of the yer of termination, indicate the quarter and year by dateCURRENT 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 urinalysirmeasurements were performed (e.g.. Co 60. U 2351. If the measured quantity of activity fcr one radionuclide is also used to estimate other radlonuclidequantities. identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See the example given in thedirections for Column 13 where U-nat(Th 2341 is entered in Column 14 indicating that the uranium lung burden was determined fromt measurements of Th234 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. Youmay use one or more of doese methods.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 detectablemeasurements followed by the highest verified result (in nanocuriesi is parentheses. On the next line in this column, enter the number of neasuremen thatindicated undetectable amounts. Specify in Column 16a42) the organ in which the indicated radionuclide war found. See die example given in the directionsfor 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 blankspace of the heading for Column 26b. In Column 16b. for each year during which urinalyses were performed. enter the nruber of detectable resultsifollowed 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 thenext line in this column. enter the number of measurements indicating undetectable amounts. See die 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 conmittedand annual doses.) For Columns 17. and 17b you are requested to follow die procedures below: if any alternative procedures are used. describe them onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (ts a minimuml of the radionuclide. Column 14. taken into the body atyour 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 thetime-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 Column12.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 STATEMENTPursuant 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 whosupply 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 40Federal Register 45344 (October 1. 1975p.1. AUTHORITY. Sections 53. 63. 65. 21. 103. 104. 161(bl. and 161(3 of dthe 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 itsstatutory 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 byindividuals 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 judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested information, including name. date of birsh. and social security number. The social security number is used to assire that NRC has an accurateidentifier 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 thelicensee must file a termination report containing certain required information, such as social security number. for each individual whose employment or work assignment hasterminated 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 maysubject the licensee lo enforcement action under 10 CFR 20.601.S. SYSTEM MANAGERtS) AND ADDRESS: Director. Office of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissionWashington. DC 2055 NRC FORM 439 U.S. NUCLEAR REGULATORY COMMISSION .DATE OF REPORT4J51 -10 CFR J20.t0REPORT OF TERMINATING INDIVIDUAL'S 2. NRC LICENSE NUTABERISOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONS.PART 1. UCENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING UCENSEE 4. NAME OF INDMDUAL mit. mWlde t. Ilal AND ADDRESS kptta5S NAME AND ADDRESS OF EMPLOYER. IF DIFFERENT FROM ABOVE tOotbirfgl. SOCIAL SECURITY NUMBER l7. ATE OF I MONtH I DAY I YEARI BIRTHPART II. EXTERNAL DOSE DATAIS PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.10 WHOLE BODY OOSF ImP A 11. EXTREMITY DOSE (mu)S. PERIODtSI OF EXFOSURE DEE SHLLWE P kir doe rwt .TOTAL b. NEUTRON c. TOTAL d. BETA SHALLOW ftahIFPART Il. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL12. PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.I6. BIOASSAY RESULTS 17. DOSE ESTIMATES (umm)u13. PERt)OISI OF EXPOSURE 14. NUCLIOE tS 11 VNO InCil b. URINALYSIS S. L COM I A C. ORGAN KSTE13. 14. NUCLIDE IS ORMAN.UINLVIVO IANlIMPC-Hrs.1trts tewil(S. II RESULTS I Li MITTED, DOSE(Il BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS2X. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REQUIREMENTS OF 10 CFR 19.13. CHECK THE FOLLOWING BOX.I YESrTo won lsaporrns d to wNdt e DpnOvi of the Maclw ReguLatory Coalason's rgulcian I0 CFR Prt 19. Vouf *tprsww Iw for ilar b b fe .I

INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individua's Occupational ExposureIf 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 reportson certain individuals so the Director. Office of Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is lo be taken fromdose records ltht must be maintained under 120.401 for individuals likely to receive exposure so radiation that exceeds a certain percentage of the NRC dose standards for die wholebody, 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 disreport is submitted. The term dosee as used 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 terminationand 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" isdefined 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 assuch.PART 1. LCENSEE AND INDIVIDUAL IDENTIFICATION DATAThis 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 thefollowing data:ITEM NUMBERI 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 thelicense 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 numbersin 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 DATAFor 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 ofany 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 NUMBER9 Specify the reporting intervals (periods of exposure) that she individual 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 forsubsequent 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 whichhas 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 ofrecord. i.e.. she highest dose received at the selected depth, from all types of external radiation sources, at any location on die body except die skin and theextremities (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 dosedelivered by all radiation incident on bhe skin, including non-trivial doses from skin contamination. which penetrates to die depth at which the shallow doseis determined. The dose at a depth of 7 mg/cm' or less, averaged over I cm2.is acceptable. If Column ICc is left blank. it will be assumed that the entryin 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 so the dose reported in Column 10. and so enter in Column l0d thecontribution 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 typespecified 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 ofunknown mignitude.10 & 11 You we r ested to enter mn or zero (in each column of 10. or in II) if the dose was undetectable. i.e., the radiation to which the worker's dosimeter wasexposed Md* response thlt you considered to be statistically indistinguishable from the response caused by inherent variabilities of the dosimetersystem. Note: It is sometimes required to add D (or its equivalent) to a real umber; although NRC regulations do not specify a Summation procedure, theNRC 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 statistianalyses.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 tospecify 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. Thedose 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 extremitydose. an entry in Column II is required only if the shallow dose exceeded the deep dose.PART m. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf 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 with520.401. 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 compliancewith 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 reportingmethods may be used. The erm bidividurd' is used 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 ofmeasurements 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 detectablereults and tie lower line for those undetectable. In 16a and/or 16b: uper I enter die number (including Iaol of detectable measurements followed inparenthesis by the highest verified result, if any: lowea line. enter thd ime ber (including zero) of meaurements iidiatisg undetectble mounts.

INSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 WContinucedl Column 13 Column 14 Column 15S Column 16I6dall 162) Itb (pCi/LI19S2 U-nm "I" 0 lung 2l2 tuns 1019S3 U-nauTh 234) 2 If7i luns 4(6)I lung 819S4 U-nst(Th 234) 1 204I tuns 12(130 lung 0Units 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 duringwhich 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 ofthis 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 ofradioactive naterial. using annual increments up to the year of termination and increments not to exceed one quarner for tde year in which the individualterminated. 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 19S31 and indicate the yew only forsubsequent 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 urinalysismeasurements were performed (e.g.. Co 6D. U 235). If the measured quantity of activity for one radlonuclide is also used to estimate other radionuclidequantities, identify the radionuclide actually measurcd in parentheses immediately after die radionmclide listed in Column 14. See the example given ini tedirections for Column 13 where U-nat(Th 234) is entered in Column 14 indicating that the uranium lung burdes was determined from measurements ofTh234 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 around the 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. Youmay 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 detectablemeasurement followed by the highest verified result (is manocuriesl in parheses. Os tde next linte it ths column. enter tde nunber ofd nmaur s thatindicated undetectable amounts. Specify in Column 16a12) the organ in which the indicated radionuclide was found. See the example gives is the directionsfor 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 blankspace of the heading for Column l6b. Is Column lob. for each year during which urinslyses were performed, enter the number of detecutble rsultfollowed 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 tdeneXt 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. (NotW that it is not necessary to provide both the committedand annual doses.) For Columns 17a and l7b you are requested to follow the procedures below: if any alternative procedures are used, describe thie onthe 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 assignmentand the year following the termination date. Base dose estimates on the quantity (s a minitum) of the radionuclide. Column 14. takes into the body atyour 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 thetime-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 Column18.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 STATEMENTPursuant 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 whosupply 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 itsstatuiory 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 byindividuals 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 as t dministraive or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMAT1ION ON INDIVIDUAL OR PERSON. It is voluntaqthat you hrnmish the requested informration. including nanie. date of birth. and social security number. The social security nunber is used to assure dath NRC has an accurateidentifier not subject to the coincidence of similar names ur birth dues among the large number of petiom on whom damt is maintained. Please note. however. that thelicensee must file a termination repont containing certain required information, such a social security number. for ecdh individual whose employment or work assignment habterminated 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 maysubject the licensee to enforcement action under 10 CrR 20.601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Office of Nucear Regulatory ResearchU.S. Nuclear Regulatory Cirnmissiam.Washington. DC 20555 NRC fORM 4S US. NUCLEAR REGULATORY COMMISSION 1. DATE OF REPORT14U1IS CFR J2.01S UBRSREPORT OF TERMINATING INDIVIDUALS NRC UCENSE NUMBERISIOCCUPATIONAL EXPOSURESEE THE ATTACHED INSTRUCTIONSOPART I. LICENSEE AND INDIVIDUAL IDENTIFICATION DATA3. NAME AND ADDRESS OF REPORTING LICENSEE 4. NAME OF INDMDUAL (firs. ni6 _ u. ls*im AND ADDRESS hp0osfa)5. NAME AND ADDRESS OF EMiPOYER. IF DIFFERENT FROM ABOVE IoptDND6. SOCIAL SECURITY NUMBER M7 OATE Of I MONTH I DAY I YEARBIRTHPART II. EXTERNAL DOSE DATAS. PERSONNEL MONITORING FOR EXTERNAL EXPOSURE TO RADIATION WAS NOT PROVIDED.la wimmf BODY WF 1{ 1 I1 EXTREMITY DOSE #mm9. PERIODISI OF EXPOSURE DEEP SHALLOW 0kng O-t dom a. TOTAL b. NEUTRON C. TOTAL d. BETA SHALLOW (skn)PART HIl. INTERNAL EXPOSURES TO RADIOACTIVE MATERIAL11.PERSONNEL MONITORING FOR EXPOSURE TO RADIOACTIVE MATERIAL WAS NOT PROVIDED.IS. BIOASSAY RESULTS 17. DOSE ESTIMATES ImmI1.ITK1.EROSIOEXOUE 14. NUCLIDE 15. FORM m. IN VIVO InCil b. URINALYSIS a. COM. b.ANNUAL c. ORGAN IMKCNrsIl1ktdieht Is, II RIESULTS I LI MITTED DOSEIt) BURDEN 121 ORGAN DOSE19. OTHER BIOASSAY RESULTS-D. IF THIS REPORT IS BEING USED TO SATISFY THE NOTIFICATION REa IREMENTS OF 10 CFA 19.13. CHECK THE FOLLOWING BOX.YES Tho ,pwf is AmWud to aou wider h provwioOfl VW1 NuCkM MoguIMorI Cwmsn8ws mpbtoon 10 CFR Part 19. You WhosL ewve On mpowt tho he ference. I

ar -4INSTRUCTIONS FOR COMPLETING NRC FORM 439,Report of Terminating Individual's Occupational ExposureIf you are licensed by the U.S. Nuclear Regulatory Commission (NRC) as specified In 120.408(a). 10 CFR Part 20. you are required to submit senrtnination radiation exposure reportson certain individuals so die Director. Office o Nuclear Regulatory Research. U.S. Nuclear Regulatory Commission. Washington. DC 20555. This information is to be bken fromdose records that must be maintained under 520.401 for individuals likely to receive exposure to radiation dtt exceed a certain percentage of the NRC dose standards for die wholebody. tin or extremities-25% for workers of age IS years or more. 5% for workers younger thn IS. The tem individual" is used below to represent die worker for whom thisreport is submitted. The tern "dose" as used in Forn 439 tmd in these instructions eferst to the dose in remt as defined in 520.4ta) and subsequendy 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 de most recent terminationand was not Interupted by any previous termination during which personnel monitoring was required by 120.202(a and/or bioassays were required by your license. "Termination" isdefined in 520.3(X 19). Parts II and I1 of this form reflect regulatory requirements as well es requests intended to stahdtrdize reporting methods: requests ar clearly identified assuch.PART 1. LICENSEE AND INDIVIDUAL IDENTIFICAllON DATAThis 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 thefollowing data:ITEM NUMBERIDte that the report was prepared.2 Current NRC license number assigned to the facility(s) in which the individual received di reported dose. If more than one license is involved, enter thelicene number for the fcility or activity under which most of the dose was incurred as he first number. If ths is ot practical. enter the license numbersin die order of original isuance.3 Name nd address of your facility as it appears on your NRC license.4 The individual's first name.- middle initial. and surname. (Address of the individuadIny be included, but hist enatered into die NRC rcords yn.5 The me and atddress of the Individual's employer. if it is different from the reporting licensee. (Optional; ot 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 DATAFor 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 dose is defined as the dose to the skin ofany past of the body. nid the extremities are defined as hands and forearms. feet and akles.item Number S If the individual was not monitored for external exposure to radiation. you are fequasux to check the box to the left nod go to Part II1.!COLUMN NUMBER9 Specify the reporting intervals (periods of exposure) that the individual was monitored at your facility(s) pursuant to 520.202 You amre sq t to use s-nual increments us to the year of termination mid Increments not so exd e quarter for the year in which tbe individual terminated:ANNUAL: Indicate the sontdi and year of the beginning date of exposure when showing annual increments (e.g., May 1979) and Indicate the year only forubset annual increments;QUARTER: For each completed quarter of the year of termination. indicate the quarter and year by dateCURRENT QUARTER: Specify the beginning and ending dates of die atual exposure period (month, day. year).Enter the following data:IO& Unless the eyes are shielded. enter the deep dose assessed at a tissue depth of 300 mg/cm' (lens depth) or less. If tbe eyes are prc by shielding whichhas a tissue equivalent thickness of 700 mgl/n' or mere. the deep dose may be assessed at 1000 mng/cm (gonad depth) or less. Enter the total dose orrecord. Le.. the highest dose received at the selected depth. from all types of extemal radiation saurces. at any location on the body except the akin arnd theextremities (hads t forearms. feet and ankles).lOc For all akin aeas, except that of the extremities, nter in column lOc the shallow dose Of record. tboed die ttna dose to the a I.Le.. the highest dosedelivered by al radiation incident on the skin, Including non-trivial doses from akin contamination. which penetrates to die depth at which the shallow doseIs determinied. Tbe dose at a depth of 7 mngtan' or less, averaged over I cma. is acceptable. If Column l0c is left blank. it will be assumed that the entryin lOa is applicable also for die shallow dose. Therefore. an entry for shallow dose is required only if It exceeds the deep dose.l~b h d You art tquested to enter in column l0b the contribution made by neutron radiation so the dose teported in Column lOs. atd so enter in Column l(o theontributhimiiaby beta radiation to the dose reported In Column lOc. Enter XXX if it Is known that there was so exposure to radiation of the typespecified in the column heading. Enter UNKIf a detectale exposure Is reported in lOa or lOc which could have included a beta or neutron contribution ofunknown magnhide.10 h 11 You re t ost enter m or zero (in ech column of 10. or in II) If the dose was undetectable. i.e.. te radiation to which the worker's dosimeter wase d xpw d ed sa rponse that yeu considered to be tistlly din shble from the esponse m used by herent wriabilia of the dsersystem. Note: Its sometimes required to add es (or its equivalent) to a real turmber; although NRC regulations do sot specify a sunuation procedure, dieNRC staff arbitrarily assigns 10 mrens to be a value of m (assuming 0.5 L 10 ( L where L is die detection limit) for die purposes of Statisticalanalyses.Reporting of die extremity dose is required. You are requested to comply In the following manner. Enter the dose of ecord. i.e.. the highest dose.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 tospecify dte extremity that received tbe dose. doses to different extreities should net be added together. The dose is so Include that delivered by al radsa-don Incident on the skin. including non-trivial doses from skin cnawmination, which penetntes to the depth at which the shallow dose Is determined. Thedose at a depth of 7 mg/cm5 or less is acceptable. If Column II Is let blank. it will be assumed that the entry in lOc is applicable also for the extremitydose; tm entry in Column I is required only If the shallow dose exceeded the deep dose.PART M. INTERNAL EXPOSURES TO RADIOACTIVE MATERIALIf you arm licensed by the NRC as specified in p0.406(a). 10 CFR Pat 20. and if your license requires bioassay services for workers at your faclity. you are required to submit ter-mination report on personnel exposures to radioactive material. containing Information that you have obtained in compliance with the license and aecorded in compliance with520.401. You wre quested ID cude in each terminstion rteport information that you have obtained in eompliance with 120.103(aX3) and 20.103(cX2) and recorded in compliancewith 120.401. This part provides for the reporting of internal monitoring procedures in terms of biotassay results. dose estimates. or hisake. Any one (or more) of these reportingmethods may be used. The term WIndividual" is used below to represent die worker for whom this report Is submitted. The term "'exposures to radioactive material" is used in cen-section with these termination reports to represent the entry of radioactive material Into the body.Item Number 12 If the individual was s t monitored for exposure to radioactive material, yOu atre u to check the box to the left: otherwise. enter the following data: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 ofmeasurements which Indicated quantities or eoncentro that 1Wcre tectable ie.. n the detction stem used. the radionudide present (if any) pro-duced a response that you considered to be statistically indistinguislhable from its background. In Column 13 enter eac year bioassay was perfoermed, 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 dotectablereults and the lower Line for those undetectable. In Ida and/or 16b: u li nter the number (including zero) of detectable measurements followed biparenthesis by the highest verified result. if any; lower line. enter thme (including zero) of measurements indicatdng sndetectable amounts.

C IYNSTRUCTIONS FOR COMPLETING NRC FORM 439 (Continued)COLUMN NUMBER13 (Continued; Column 13 Column 14 Column 13 Column 16l6all) 16f21 l6b (pCUL1932 U-nat 1 0 lung VI)2 lung 1o1983 U-natth 2341 I 1..7 lung 4(61Ilung S1934 U-nat(Th 2341 1 2(14 lung 12(13)0 lung 0Units for die numbers in parentheses shown in Column 16b are to be specified in the heading for Column 16b. If Columns 17 or IS are conmplted. nota-tions in Column 16 are unnecessary.If the dose commitment 150-year integrated dose) is reported. indicate in Column 13 by beginning and ending dares (month. day. year) td period duringwhich tde associated radioactive material was taken into te body.If annual doses are reported. enter in Column 13 tde calendar year over which each dose was integrated. including the first and any succeeding yearn ofthis employment or work assignmernt and the year following the termination date.For entries in Column 18 (intake;. specify the reporting intervals (periods of exposure) during which die individual was exposed to concentrations ofradioactive material. using annual increments up to the year of termination and increments not to exceed.one quarter for the year in which die individualterminated. The periods of exposure for intake& should appear as follows:ANNUAL: Indicate the month and year of the beginning date of exposure when showing annual increments (e.g.. June 1983) and indicate tie year only forsubsequent annual increments.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 urinalysismeasurements were performed (e.g.. Co 60. U 235;. If the measured quantity of activity for one radionudida is alao used to essimate other radionuclidtquantities identify the radionuclide actually measured in parentheses immediately after the radionuclide listed in Column 14. See die example gives ia thedirections for Column 13 where U-nat(Th 234; is entered in Column 14 indicating that the uranium lung burden was determined from measurements of Tl234 photons.is Enter the form. S for soluble or I for insoluble. of the radionuclide to which tie worker was exposed. if unknown. use quoes around the letter. thus in-dicating which concentration value in Part 20. Appendix B. Table 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 or ie. Youmay use one or more of these methods.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 detectablemeasurements followed by the highest verified result (in nanocuries; In parentheses. On the next line is this column. enter the number of meatiremenUs thatindicated undetectable amounts. Specify in Column 16c(21 the organ in which the indicated radionuclide was found. See the example given in dte direction.for Column 13.16b Firm enter the grnvimetric or radionetrik unit in which the urinalysis results are reported (eg.. micrograms per liter. nanocuries per Iter) is the blankspace of the heading for Column 16b. In Column 16b. for each year during which urinalyses were performed, enter the numiber of detectable resultsfollowed 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 tdenext line in this column. enser the number of measurements indicating 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 in Column 17a or 17b. (Note thdt it is not necessary to provide both the committedand annual doses.; For Columns 17a and 17b you amr requested to follow the procedures below: if any alternative procedures ae used. describe themn onsthe back of this forta. In 17a. enter the dose integrated from t to 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 or work assignmentand the yer following the termination date. Base dose estimates on the quantity fa a minimum; of the radionuclide, Column 14. taken into the body atyour facility(sl during this employment or work-assignment period.IS Reporting of radionuclide intakes. as determined by air sampling. is not required by 10 CFR 20.401. However. should this option be chosea indicate thetime-weighted concentrations of radioactive material (i.e.. MPC-hoursn to which the individual was exposed during the time perioda indicated in Column 13.Refer to te 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 ColumnItem 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 STATEMENTPursuant 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 to individuals and personn whosupply informatio so the Nuclear Regulatory Commission on NRC Form 439. This information Ls maintained in a system of records designated as NRC-27 and described at 40Federal Register 45344 (October 1. 1975).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. 2073. 2093. 2095. 2111. 2133. 2134.2201fb;. and 22014o);. The authority for soliciting the social security number is 10 CFR Parn 20.2. PRINCIPAL

PURPOSE

(S). The information is used by the NRC in its evaluatipn of the risk of radiation exposure associatedwibh the licensed activity and in exercising itsstatutory responsibility to monitor and regulate the safety and health practices of its licensees. The dat permit a metninghi comprison of both current and long-tern ex-posure experience among types of licenees and among licensees within each type. Data on your exposure to radiation ar avaible to you upot t request3. ROUTINE USES. The information mny be used lo provide data to other Federal and State agencies involved in monitoring and/or evaluating radiation expoture received byindividuals employed as radiation workers on a penranent or temporary basis and exposure received by monitored visitors. The information may alto be disclosed to an ap-propriae Federal. State. or local agency in te event the information indicates a violation or potential violation of law and in the course of an adinini v or judicialproceeding.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT OF NOT PROVIDING INFORMATION ON INDIVIDUAL OR PERSON. It is voluntarythat you furnish the requested infornation. including name. date of birth. and social security number. The social security number is used to assure that NRC has an accurateidentifier not subject to the coincidence or similar names or birth dates among the large number of persons on whom data is maintaied. Please note. however. that thelicensee rmost file termination report containing certain required information. such as social security number. for each individual whose employment or work assignment haterminated and for whom personnel monitoring was required under 10 CFR 20.202. Failure of the licensee to provide the information under 10 CFR l20.202 and 20.408 maysubject the licensee to enforcement action under 10 CFR 20Q601.5. SYSTEM MANAGER(S) AND ADDRESS: Director. Offi e of Nuclear Regulatory ResearchU.S. Nuclear Regulatory CommissitnWashingt. DC 20555 jLIST OF RECENTLY ISSUED GENERIC LETTERSGENERICLETTER NO. SUBJECT DATE84-20 Scheduling Guidance for Licensee Submittalsof Reloads that Involve Unreviewed SafetyQuestions 8/20/8484-21 Long Term Low Power Operation in PWR's 10/16/8484-22 Not used84-23 Reactor Vessel Water Level Instrumentationin BWRs 10/26/8484-24 Clarification of Compliance to 10 CFR 50.49Environmental Qualification of ElectricalEquipment Important to Safety for NuclearPower Plants 12/27/8485-01 Fire Protection Policy Steering CommitteeReport 1/9/8585-02 Staff Recommended Actions Stemming From NRCIntegrated Program for the Resolution ofUnresolved Safety Issues Regarding SteamGenerator Tube Integrity 4/15/8585-03 Clarification of Equivalent Control Capacity 1/28/85For Standby Liquid Control Systems85-04 Operator Licensing Examinations 1/29/8585-05 Inadvertent Boron Dilution Events 1/31/8585-06 Quality Assurance Guidance for ATWSEquipment that is not Safety-Related 4/16/8585-07 Implementation of Integrated Schedules 5/02/85for Plant Modifications85-08 10 CFR 20.408 Termination Reports -Format 5/23/8585-09 Technical Specifications for GenericLetter 83-28, Item 4.3 5/23/8585-10 Technical Specifications for GenericLetter 83-28, Items 4.3 and 4.4 5/23/85

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