ML19213A236

OMB 3150-0218, NRC Form 850 (OMB Copy)

ML19213A236
Person / Time
Issue date:	09/27/2019
From:	NRC/OCIO
To:
References
OMB 3150-0218
Download: ML19213A236 (2)

Text

NRC FORM 850 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0218 EXPIRES: (MM/DD/YYYY)

(MM-YYYY) Estimated burden per response to comply with this mandatory collection request: 10 minutes. The agency uses the information on this form to initiate a background investigation on NRC contractors. Send comments regarding burden estimate to the Information Services REQUEST FOR CONTRACTOR Branch (T-6 A10M), 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, (3150-0218), Office of Management and Budget, ASSIGNMENT(S) 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.

Purpose of this form:

This form is part of the Security Package and is used to: 1) process a new contractor to the NRC; 2) process a contractor requiring an access or clearance upgrade; or 3) adding an additional contract to an existing NRC Contractor.

Questions relating to this form, or the Contractor Access Program, should be directed to PSB_ContractorResourceInbox@nrc.gov.

Questions related to badge issuance and access times should be directed to Badge.Resource@nrc.gov.

Personal Contractor Information Legal Legal Legal First Middle Last Name: Name: Name:

SSN:

Date of Birth:

(Enter 9 City of Birth:

(MM/DD/YYYY) numbers)

State of Birth:

(If applicable) Select Country: Select Current Address:

(Number, street, city, state, and zip code)

Daytime E-mail Telephone Number:

Address:

(XXX) XXX-XXXX Foreign Country U.S. Foreign Citizenship:

Citizen or Country

- of Citizenship: Select (If applicable)

I Authorize the Personnel Security Branch (PSB) to process the contractor as stated in the document.

COR's Signature Contract Information Reason For Contract Expiration Submission: Select Date: (MM/DD/YYYY)

Contract Company Name:

Contract Number:

(EWC, BPA, or Main)

COR's Name:

Alternate COR's Name:

Type of Is this a Drug Testing Type of Badge Access Select Position? (See NRC 188) Select Access Needed? Select Needed: Select Yes or No (Select One)

Task Order Information (if applicable)

Type of Access Badge required for Drug Testing Position?

Task Order Task Order Needed for this this Task Order? (See NRC 188)

Number Expiration Date Task Order Type Yes or No Type Yes or No Select Submit by E-mail NRC FORM 850 (MM-YYYY) Page 1 of 2

NRC FORM 850 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

REQUEST FOR CONTRACTOR ASSIGNMENT(S) (Continued)

PRIVACY ACT STATEMENT NRC FORM 850 Request for Contractor Assignment(s)

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form 850. This information is maintained in a system of records designated as NRC-39, described at 81 Federal Register 81348 (November 17, 2016), or the most recent Federal Register publication of the system of records notice for NRC-39, available at https://www.nrc.gov/reading-rm/foia/privacy-systems.html and in the NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 42 U.S.C. 2011 et seq.; 42 U.S.C. 2165, 2201(i), 2201a, and 2284; 42 U.S.C. 5801 et seq.;

Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O. 10450, as amended; E.O. 10865, as mended; E.O.

13467; E.O. 13526; E.O. 13587; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised; 5 CFR parts 731, 732, and authorities cited therein.

2. PRINCIPAL PURPOSE(S): To obtain necessary building access authorization for NRC contractors, subcontractors, or other individuals who are not applicants for employment with NRC.

3. ROUTINE USE(S): Information in these records may be used by the Division of Facilities and Security and on a need-to-know basis by appropriate NRC officials, Hearing Examiners, Personnel Security Review Panel members, Office of Personnel Management, Central Intelligence Agency, and other Federal agencies: to determine clearance or access authorization eligibility; to determine eligibility for access to NRC buildings or access to Federal automated information systems or data; to certify clearance or access authorization; to maintain the NRC personnel security program; and to provide licensees information needed for unescorted access or access to safeguard information determinations. The information may also be disclosed on a need-to-know basis to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law, regulation, or order; to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you; in the course of discovery, in presenting evidence to a court, magistrate, administrative tribunal, or grand jury or pursuant to an order from any of those, in alternative dispute resolution proceedings, or in the course of settlement negotiations; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC; to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records; and to the National Archives and Records Administration, Office of Government Information Services (OGIS), to the extent necessary to allow OGIS to fulfill its responsibilities under the Freedom of Information Act (5 U.S.C. 552).

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosing this information is voluntary; however, if you do not provide the requested information, your access authorization or clearance request cannot be processed.

5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 850 (MM-YYYY) Page 2 of 2