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NRC FORM 4
U.S. NUCLEAR REGULATORY COMMISSION
(M-YYYY)
10 CFR PART 20
EXPIRES: MM/DD/YYYY
Estimated burden per response to comply with this mandatory collection request: 30 minutes. This
information is required to record an individual's lifetime occupational exposure to radiation to ensure that
the cumulative exposure to radiation does not exceed regulatory limits. Send comments regarding burden
estimate to the Information Services Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington,
DC 20555-0001, or by internet e-mail to infocollects.resource@nrc.gov, and to the Desk Officer, Office of
Information and Regulatory Affairs, NEOB-10202, (3150-0005), 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.
CUMULATIVE OCCUPATIONAL DOSE HISTORY
1. NAME (LAST, FIRST, MIDDLE INITIAL)
APPROVED BY OMB NO.3150-0005
OF
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
MALE
5. DATE OF BIRTH
(MM/DD/YYYY)
FEMALE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
12. LDE
13. SDE, WB
8. LICENSE NUMBER
14. SDE, ME
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
12. LDE
13. SDE, WB
12. LDE
13. SDE, WB
14. SDE, ME
12. LDE
13. SDE, WB
14. SDE, ME
12. LDE
13. SDE, WB
14. SDE, ME
12. LDE
19. SIGNATURE OF MONITORED INDIVIDUAL
NRC FORM 4 (M-YYYY)
15. CEDE
16. CDE
15. CEDE
16. CDE
8. LICENSE NUMBER
14. SDE, ME
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
16. CDE
8. LICENSE NUMBER
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
15. CEDE
8. LICENSE NUMBER
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
16. CDE
8. LICENSE NUMBER
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
11. DDE
15. CEDE
9.
15. CEDE
16. CDE
8. LICENSE NUMBER
13. SDE, WB
14. SDE, ME
15. CEDE
20. DATE SIGNED
21. CERTIFYING ORGANIZATION
16. CDE
RECORD
ESTIMATE
NO RECORD
10.
ROUTINE
PSE
17. TEDE
18. TODE
9.
10.
RECORD
ESTIMATE
NO RECORD
ROUTINE
PSE
17. TEDE
18. TODE
9.
10.
RECORD
ESTIMATE
NO RECORD
ROUTINE
PSE
17. TEDE
18. TODE
9.
10.
RECORD
ESTIMATE
NO RECORD
ROUTINE
PSE
17. TEDE
18. TODE
9.
10.
RECORD
ESTIMATE
NO RECORD
ROUTINE
PSE
17. TEDE
18. TODE
9.
10.
RECORD
ESTIMATE
NO RECORD
17. TEDE
22. SIGNATURE OF DESIGNEE
ROUTINE
PSE
18. TODE
23. DATE SIGNED
INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 4
(All doses should be stated in rems)
1.
Type or print the full name of the monitored
individual in the order of last name (include "Jr,"
"Sr," "III," etc.), first name, middle initial (if
applicable).
2.
Enter the individual's identification number,
including punctuation. This number should be
the 9-digit social security number if at all
possible. If the individual has no social security
number, enter the number from another official
identification such as a passport or work permit.
3.
Enter the code for the type of identification used
as shown below:
CODE ID TYPE
SSN U.S. Social Security Number
PPN Passport Number
CSI
Canadian Social Insurance Number
WPN Work Permit Number
PADS PADS Identification Number
OTH Other
4.
Check the box that denotes the sex of the
individual being monitored.
5.
Enter the date of birth of the individual being
monitored in the format MM/DD/YYYY.
6.
Enter the monitoring period for which this report
is filed. The format should be MM/DD/YYYY MM/DD/YYYY.
7.
Enter the name of the licensee or facility not
licensed by NRC that provided monitoring.
8.
Enter the NRC license number or numbers.
9.
Place an "X" in Record, Estimate, or No Record.
Choose "Record" if the dose data listed
represent a final determination of the dose
received to the best of the licensee's
knowledge. Choose "Estimate" only if the listed
dose data are preliminary and will be
superseded by a final determination resulting in
a subsequent report. An example of such an
instance would be dose data based on
self-reading dosimeter results and the licensee
intends to assign the record dose on the basis
of TLD results that are not yet available. If the
individual or an organization has indicated that
the individual was monitored, but the monitoring
records could not be obtained, enter "No
Record" for this monitoring period. The
individual would not be available for a PSE. For
monitoring periods during the current year
where records are not available, reduce the
individual's allowable dose by 1.25 rems for
each quarter for which records were unavailable
as required by 10 CFR 20.2104(e)(1).
10. Place an "X" in either Routine or PSE.
Choose "Routine" if the data represent the
results of monitoring for routine exposures.
Choose "PSE" if the listed dose data
represents the results of monitoring of
planned special exposures received during the
monitoring period.
11.
Enter the deep dose equivalent (DDE) to the
whole body.
12.
Enter the eye dose equivalent (LDE) recorded
for the lens of the eye.
13.
Enter the shallow dose equivalent recorded for
the skin of the whole body (SDE,WB).
14.
Enter the shallow dose equivalent recorded for
the skin of the extremity receiving the
maximum dose (SDE,ME).
15.
Enter the committed effective dose equivalent
(CEDE).
16.
Enter the committed dose equivalent (CDE)
recorded for the maximally exposed organ.
17.
Enter the total effective dose equivalent
(TEDE). The TEDE is the sum of items 11 and
18. 15.
19.
20.
21.
22.
23.
PRIVACY ACT STATEMENT
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 U.S. Nuclear Regulatory Commission (NRC) on NRC Form 4. This
information is maintained in a system of records designated as NRC-27 and described at 71
Federal Register 59634 (October 10, 2006), or the most recent Federal Register publication
of the NRC's Systems of Records Notices that is located in NRC's Agencywide Documents
Access and Management System (ADAMS).
1.
AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2051, 2073, 2093, 2095, 2111,
2133, 2134, and 2201(o); 10 CFR 20.2106, 20.2201-20.2204, and 20.2206; Executive
Order (E.O.) 9397; E.O. 12196, as amended by E.O.s 12223, 12608; E.O. 12258; E.O.
12399; E.O. 12489; E.O. 12534; E.O. 12610; E.O. 12692.
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 its
statutory responsibility to monitor and regulate the safety and health practices of its
licensees. The data permits a meaningful comparison of both current and long-term
exposure experience among types of licensees and among licensees within each type.
Data on your exposure to radiation is available to you upon your request.
3. ROUTINE USE(S): The information may be used to provide data to other Federal and
State agencies involved in monitoring and/or evaluating radiation exposure received by
individuals monitored for radiation exposure while employed by or visiting or temporarily
assigned to certain NRC licensed facilities; to return data provided by licensee upon
request. Information may be disclosed in accordance with any of the Routine Uses
listed in the Prefatory Statement of General Routine Uses, including to an appropriate
Federal, State, local or Foreign agency in the event the information indicates a violation
Enter the total organ dose equivalent (TODE)
or potential violation of law; in the course of an administrative or judicial proceeding; to
for the maximally exposed organ. The TODE
an appropriate Federal, State, local and foreign agency to the extent relevant and
is the sum of items 11 and 16.
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 under a protective order
Signature of the monitored individual. The
signature of the monitored individual on this
issued by a court of competent jurisdiction, and in presenting evidence; to a
form indicates that the information contained
Congressional office to respond to their inquiry made at your request; to NRC-paid
on the form is complete and correct to the best
experts, consultants, and others under contract with the NRC, on a need-to-know basis;
of his or her knowledge.
or 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.
Enter the date this form was signed by the
monitored individual.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
[OPTIONAL] Enter the name of the licensee or
INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the
facility not licensed by NRC, providing
requested information, including the Social Security number (SSN) in block #2. The
monitoring for exposure to radiation (such as a
SSN is used to assure that NRC has an accurate identifier not subject to the
DOE facility) or the employer if the individual is
not employed by the licensee and the
coincidence of similar names or birth dates among the large number of persons on who
employer chooses to maintain exposure
data is maintained and to assure that there are no missed doses or monitoring periods
records for its employees.
and an individual gets a complete dose history when requested. The licensee must
complete NRC Form 5 on each individual for whom personnel monitoring is required
[OPTIONAL] Signature of the person
under 10 CFR 20.2106. Failure to do so may subject the licensee to enforcement
designated to represent the licensee or
employer entered in item 21. The licensee or
action in accordance with 10 CFR 20.2401.
employer who chooses to countersign the form
should have on file documentation of all the
SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Office of Nuclear
information on the NRC Form 4 being signed. 5.
Regulatory Research, U.S. Nuclear Regulatory Commission, Washington, DC
20555-0001.
[OPTIONAL] Enter the date this form was
signed by the designated representative.
| File Type | application/pdf |
| File Title | c:\temp\ffdah1.wpf |
| Author | DAH1 |
| File Modified | 2010-10-28 |
| File Created | 2010-10-28 |