Description of Information Collections

OFFICE OF SECURITY AND SAFETY PERFORMANCE ASSURANCE
INFORMATION COLLECTION PACKAGE
HUMAN RELIABILITY PROGRAM
OMB 1910-5122
Description of Collections
(Detail for Item 2 of the Support Statement)
February 22, 2007
1. Human Reliability Program (HRP) Certification. Under the Department of Energy
Human Reliability Program (HRP), individuals who are applicants for or incumbents in
designated positions must be evaluated to ensure that they meet the requirements for
certification in the program. After the initial evaluation, incumbents in HRP positions are
evaluated annually. The evaluations are performed by the individual’s immediate
supervisor, the HRP management official at the site where the individual works, the Site
Occupational Medical Director, and the personnel security office which holds the
individual’s personnel security file. In addition, the individual is required to undergo
alcohol and drug screenings and an evaluation by the Office of Counterintelligence. This
form documents that each part of the evaluation has been completed and records the
determination by the HRP Certifying Official. The collection and documentation of this
information is required by the Human Reliability Program regulation found in the Code
of Federal Regulations at 10 CFR 712.
2. Acknowledgement and Agreement to Participate in the Human Reliability
Program (HRP). This form documents an individual’s consent to participate in the
Human Reliability Program and his or her acknowledgement that he or she is fully aware
of all of the requirements for participation in the program. This includes medical and
psychological assessments and drug and alcohol testing. The individual’s signature on
this form is required by 10 CFR 712.11(a)(3), General requirements for HRP
certification.
3. Authorization and consent to release Human Reliability Program (HRP) Records
in Connection with the HRP. This individual’s signature on this form documents his or
her authorization to release medical and non-medical records developed during the HRP
certification process and relevant to his or her eligibility to occupy an HPR position. The
form authorizes the release of these records to those contractor management and DOE
officials who have a legitimate need for the information in the performance of their duties
and responsibilities under the HRP process. The individual’s signature on this form as a
condition of certification in the HRP is required by 10 CFR 712.11(a)(3).
4. Refusal of Consent. This form documents an individual’s acknowledgement that,
after being provided with full information on the requirements of the HRP, he or she
declines to participate in the program and understands that he or she will not be assigned
to an HRP position.

5. Human Reliability Program (HRP) Alcohol Testing Form. This form documents
breath alcohol test procedures conducted under the HRP, as well as the individual’s
acknowledgement that the identifying information entered on the form is correct. If the
individual is found to have a blood alcohol level greater than the limit specified under the
HRP, the individual also signs this form to acknowledge understanding that he or she will
be sent home and will not be allowed to return to HRP duties for 24 hours. The
collection and documentation of this information is authorized by 10 CFR 712.15(c),
Alcohol testing.