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Category:NRC Forms (Blank)
MONTHYEARML22192A1972022-07-11011 July 2022
NRC Form 446 - Request for Approval of Official Foreign Travel by Non-Government Personnel (*Must Be Completed 30 Days Prior to Travel)
ML21148A2422021-05-28028 May 2021
NRC Form 149 - Ocfo Invitational Traveler Request Form
ML20339A6732021-01-12012 January 2021
NRC Form 529 - Dispute of Fees-for-Service Charges in Accordance with Title 10 of the Code of Federal Regulations (10 CFR) 170.51
ML12164A7272020-01-31031 January 2020
NRC Form 313A (Amp), Authorized Medical Physicist or Ophthalmic Physicist, Training, Experience and Preceptor Attestation (10 CFR 35.51, 35.57(a)(3), and 35.433). (01-2020)
ML12164A7282020-01-31031 January 2020
NRC Form 313A (Anp), Authorized Nuclear Pharmacist Training, Experience, and Preceptor Attestation (10 CFR 35.55). (01-2020)
ML12164A7332020-01-31031 January 2020
NRC Form 313A (Aud), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.100, 35.200, and 35.500) (10 CFR 35.57, 35.190, 35.290, and 35.590). (01-2020)
ML12164A7362020-01-31031 January 2020
NRC Form 313A (Aus), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.400 and 35.600) (10 CFR 35.57, 35.490, 35.491, and 35.690). (01-2020)
ML12164A7412020-01-31031 January 2020
NRC Form 313A (Aut), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.300)(10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396). (01-2020)
ML12164A7422020-01-31031 January 2020
NRC Form 313A (Rso), Radiation Safety Officer or Associate Radiation Safety Officer Training, Experience, and Preceptor Attestation (10 CFR 35.57, 35.50). (01-2020)
ML13083A1032019-10-31031 October 2019
NRC Form 361N - Non-Power Reactor (NPR) Event Notification Worksheet
ML13083A0722019-09-30030 September 2019
NRC Form 313 - Application for Materials License
ML13083A0192019-07-31031 July 2019
NRC Form 7 - Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(S)
ML13083A1232019-07-31031 July 2019
NRC Form 396 - Certification of Medical Examination by Facility Licensee
ML13083A1272019-07-31031 July 2019
NRC Form 398 - Personal Qualification Statement -- Licensee
ML13083A1742019-07-31031 July 2019
NRC Form 526 - Certification of Small Entity Status for the Purposes of Annual Fees Imposed Under 10 CFR Part 171 (Effective July 16, 2019)
ML13083A1762019-05-31031 May 2019
NRC Form 531 - Request for Taxpayer Identification Number
ML13083A2502019-04-30030 April 2019
NRC Form 664 - General Licensee Registration
ML19231A2062019-01-31031 January 2019
NRC Form 527 - Request for Information Related to Contractor Charges -- in Accordance with 10 CFR 170.51
ML16025A0332018-12-31031 December 2018
NRC Form 405F - List All Owners, Officers, Directors, and Executive Personnel (Oodep'S)
ML13083A1372018-10-31031 October 2018
NRC Form 426 - Authorization to Publish a Manuscript in the NUREG Series
ML13083A0942018-06-30030 June 2018
NRC Form 354 - Data Report on Spouse
ML13083A1422018-05-31031 May 2018
NRC Form 445 - Request for Approval of Official Foreign Travel
ML13083A1522018-04-30030 April 2018
NRC Form 483 - Registration Certificate -- in Vitro Testing with Byproduct Material Under General License
ML13083A1072018-04-30030 April 2018
NRC Form 366A - Licensee Event Report (LER) Continuation Sheet
ML13083A1062018-04-30030 April 2018
NRC Form 366 - Licensee Event Report (LER)
ML13083A2952018-04-30030 April 2018
NRC Form 740M - Concise Note
ML13083A2972018-04-30030 April 2018
NRC Form 742 - Material Balance Report
ML13083A2982018-04-30030 April 2018
NRC Form 742C - Physical Inventory Listing
ML13083A2962018-04-30030 April 2018
NRC Form 741 - Nuclear Material Transaction Report
ML13083A2442018-02-28028 February 2018
NRC Form 653 - Transfers of Industrial Devices Report (to General Licensees)
ML13083A1082018-02-28028 February 2018
NRC Form 366B - Licensee Event Report (LER)
ML13114A5072017-12-31031 December 2017
NRC Form 782 - Complaint Form
ML13083A3292017-12-31031 December 2017
NRC Form 781 - Sbcr Compliance Review Part a
ML13083A1792017-11-30030 November 2017
NRC Form 536 - Operator Licensing Examination Data
ML13083A0172017-10-31031 October 2017
NRC Form 5 - Occupational Dose Record for Monitoring Period
ML13083A0052017-10-31031 October 2017
NRC Form 4 - Cumulative Occupational Dose History
ML13083A0182017-10-31031 October 2017
NRC Form 64 - Travel Voucher
ML13083A0592017-10-31031 October 2017
NRC Form 241 - Report of Proposed Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, or Offshore Waters
ML14211A1652017-09-30030 September 2017
NRC Form 749 - Manual License Verification Report
ML13083A0022017-08-31031 August 2017
NRC Form 3 - Notice to Employees
ML13083A2372017-07-31031 July 2017
NRC Form 629 - Authorization for Payment by Credit Card
ML13083A0502017-05-31031 May 2017
NRC Form 212 - Qualifications Investigation Professional, Technical, and Administrative Positions
ML13083A0852017-03-31031 March 2017
NRC Form 327 - Special Nuclear Material (SNM) and Source Material (SM) Physical Inventory Summary Report
ML19231A1992017-03-31031 March 2017
NRC Form 787 - Freedom of Information Act - User Survey
ML13083A0792017-02-28028 February 2017
NRC Form 314 - Certificate of Disposition of Materials
ML13083A1802017-01-31031 January 2017
NRC Form 540 - NRC Uniform Low-Level Radioactive Waste Manifest Shipping Paper
ML13083A1812017-01-31031 January 2017
NRC Form 540A - Uniform Low-Level Radioactive Waste Manifest Shipping Paper (Continuation)
ML13083A1822017-01-31031 January 2017
NRC Form 541 - Uniform Low-Level Radioactive Waste Manifest Container and Waste Description
ML13083A0282017-01-31031 January 2017
NRC Form 136 - Security Termination Statement
ML13083A1832017-01-31031 January 2017
NRC Form 541A - Uniform Low-Level Radioactive Waste Manifest Container and Waster Description (Continuation)
2022-07-11
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5. MATERIAL TYPE (Submit separate report for each type)
U.S. DEPARTMENT OF ENERGY AND U.S. NUCLEAR REGULATORY COMMISSION
- 1. NAME AND ADDRESS MATERIAL ACCOUNTABILITY NRC FORM 742 (04-2018)
- 4. REPORT PERIOD (MM/DD/YYYY)
APPROVED BY OMB: NO. 3150-0004 DOE/NRC FORM 742
- 2. LICENSE NUMBER(S)
- 3. REPORTING IDENTIFICATION SYMBOL (RIS)
FROM TO SECTION A 8. BEGINNING INVENTORY -- U.S. GOVT-OWNED
- 9. BEGINNING INVENTORY -- NOT U.S. GOVT-OWNED
- 11. PROCUREMENT FROM DOE RIS FROM: 13. PROCUREMENT -- FOR THE ACCOUNT OF DOE
- 14. DOD RETURNS -- USE A
- 15. DOD RETURNS -- USE B
- 16. DOD RETURNS -- OTHER USES
- 21. PRODUCTION
- a. ICT
- b. ICT
- c. ICT 30. RECEIPTS REPORTED TO DOE/NRC ON DOE/NRC 741 (not listed elsewhere)
FROM: 34. RECEIPTS -- MISC
- 37. PROCUREMENT BY OTHERS
- 38. DONATED MATERIAL -- FROM U.S. GOVT TO OTHERS
- 39. DONATED MATERIAL -- FROM OTHERS TO U.S. GOVT
- 40. TOTAL (Lines 8-39)
- 41. EXPENDED IN SPACE PROGRAMS RIS TO: RIS TO: 44. DOD -- USE A
- 45. DOD -- USE B
- 46. DOD -- OTHER USES
- 47. EXPENDED IN U.S. GOVT TESTS
- 48. ROUTINE TESTS
- 49. SHIPPER -- RECEIVER DIFFERENCE
- 51. SHIPMENTS REPORTED TO NRC/DOE ON NRC/DOE 741 (not listed elsewhere)
TO: RIS EXPIRES: 04/30/2021 RIS 22. FROM OTHER MATERIALS
- 42. SALES TO U.S. GOVT RIS TO:
- 43. SALES TO OTHERS FOR THE ACCOUNT OF U.S. GOVT (04-2018)10 CFR 30, 40, 50, 70, 72, 74, 75, 150, Public Laws83-703, 93-438, 95-91 PC SEQ MATERIAL BALANCE REPORT A. ELEMENT WEIGHT B. ISOTOPE WEIGHT RECEIPTS REMOVALS Estimated burden per response to comply with this mandatory collection request: 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> for small licensees and 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> for large licensees.
Reported lessons learned are incorporated into the licensing process and fed back to industry.
Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0004), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
Page 1 MANDATORY DATA COLLECTION AUTHORIZED BY DATE SIGNATURE (See instructions for provisions on confidentially)
TITLE 54. SHIPMENTS -- MISC
- 65. ROUNDING ADJUSTMENT
- 58. DONATED MATERIAL -- TO U.S. GOVT BY OTHERS
- 59. DONATED MATERIAL -- TO OTHERS BY U.S. GOVT
- a. ICT
- b. ICT 72. DECAY
- 75. ACCIDENTAL LOSSES
- 73. FISSION AND TRANSMUTATION
- 74. NORMAL OPERATIONAL LOSSES/MEASURED DISCARDS
- 77. INVENTORY DIFFERENCE
- 82. TOTAL (Lines 41-81)
- 80. ENDING INVENTORY -- U.S. GOVT OWNED
- 81. ENDING INVENTORY -- NOT U.S. GOVT OWNED MATERIAL ACCOUNTABILITY SECTION A (Continued)
FOREIGN OBLIGATIONS SECTION B CERTIFICATION SECTION C To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.
WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL, AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1001
MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY
OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
- 83. BIAS ADJUSTMENT
- 71. DEGRADATION TO OTHER MATERIALS
- 76. APPROVED WRITE-OFFS PC SEQ PC SEQ A. ELEMENT WEIGHT B. ISOTOPE WEIGHT
- 2. ELEMENT WEIGHT
- 3. ISOTOPE WEIGHT
- 1. COUNTRY OF OBLIGATION
- 4. TOTAL WEIGHT U.S. DEPARTMENT OF ENERGY AND U.S. NUCLEAR REGULATORY COMMISSION DOE/NRC FORM 742 (04-2018)10 CFR 30, 40, 50, 70, 72, 74, 75, 150, Public Laws83-703, 93-438, 95-91 MATERIAL BALANCE REPORT (Continued)
Page 2 NRC FORM 742 (04-2018)