NRC Form 4, Cumulative Occupational Exposure History

Forms and Documents

Document Name	Status
Form NRC Form 4 NRC Form 4, Cumulative Occupational Exposure History Form and Instruction	Modified
83-C Justification 2009 Form 4 Rev [2].doc Justification for No Material/Nonsubstantive Change	2009-06-23
2009 83 C for Form 4 -Justification.doc Justification for No Material/Nonsubstantive Change	2009-03-02
19 20 50 Final Rule Supporting Statement.doc Supporting Statement A	2007-11-28

IC Document Collections

IC ID	Document Title	Status
33127	NRC Form 4, Cumulative Occupational Exposure History Form and Instruction	Modified

ICR Details

OMB Control No: 3150-0005	ICR Reference No: 200903-3150-001
Status: Historical Active	Previous ICR Reference No: 200711-3150-005
Agency/Subagency: NRC	Agency Tracking No:
Title: NRC Form 4, Cumulative Occupational Exposure History
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/02/2009
	Date Received in OIRA: 03/04/2009
Terms of Clearance: Agency submitted additional 83-C explanation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	02/28/2011	02/28/2011
Responses	257	0	227
Time Burden (Hours)	64	0	43
Cost Burden (Dollars)	0	0	0

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Abstract: NRC Form 4 is used to record the summary of an individual's cumulative occupational radiation dose up to and including the current year to ensure that the dose does not exceed regulatory limits.

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Authorizing Statute(s): PL: Pub.L. 83 - 703 1-311 Name of Law: Atomic Energy Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
3150-AH40	Final or interim final rulemaking	71 FR 55382	09/22/2006

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 55382	09/22/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NRC Form 4, Cumulative Occupational Exposure History	NRC Form 4	Cumulative Occupational Dose History

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	257	227	0	0	30	0
Annual Time Burden (Hours)	64	43	0	0	21	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Nuclear Regulatory Commission (NRC) amended its regulations to include jurisdiction over discrete sources of radium-226, accelerator-produced radioactive materials, and discrete sources of naturally occurring radioactive material, as required by the Energy Policy Act of 2005 (EPAct), which was signed into law on August 8, 2005. This provides a regulatory framework by which to license and regulate byproduct material in accordance with the new, expanded definition. The amended regulations impacted numerous existing information collections. The NRC packaged all of the impacted information collections into one new information collection which OMB approved and assigned control number 3150-0203. The clearance affecting this 83-C is NRC Form 4, “Cumulative Occupational Exposure History,” which is currently covered under OMB Clearance 3150-0005. This form is used by licensees to maintain a cumulative summary of personnel occupational exposure history. The purpose of this 83-C is to transfer burden from OMB Clearance 3150-0203, “10 CFR Parts 20, 30, 31, 32, & 35, Requirements for Expanded Definition of Byproduct Material, Final Rule and NRC Forms 4, 5, 313, 314, & 664,” to OMB Clearance 3150-0005, “Cumulative Occupational Exposure History,” which was contained in the final approved on 8/23/07. Once the entire burden for 3150-0203 has been transferred to the correct clearances, we will submit an 83-D to discontinue 3150-0203. A total of 21 hours will be transferred to 3150-0005, resulting in a revised burden of 64 hours.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/04/2009

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