Form NRC Form 445 NRC Form 445 REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 445
(MM-YYYY)
NRC MD 14.1

REQUEST FOR APPROVAL OF
OFFICIAL FOREIGN TRAVEL

APPROVED BY OMB: NO. 3150-0193

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this voluntary collection request: 2 hours. NRC uses this form to
authorize foreign travel for non-Federal personnel in the course of conducting business for the NRC. 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, (3150-0193), 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 .

A. TRAVELER INFORMATION (To be completed by traveler)
Name of Traveler

Position Title

Country of Travel

Departure Date

Return Date

Is your official passport valid?

Does your trip require a visa?

Yes

Yes

No

No

I will adhere to all ethical codes of conduct while on travel. I understand that I must contact the NRC
Health Center (301) 415-8400 to consult on possible medical issues and precautions, including
recommended inoculations or other medications and educational materials.
Signature of Traveler

Signature Date

Purpose of Travel (Please provide a brief description of the purpose for your travel. Please spell out all acronyms.)

List of Persons with whom Travel has been coordinated (Name and Agency)
NAME
AGENCY/OFFICE

(i.e., Supervisor, OIP Desk Officer, other travelers)

B. REVIEW AND APPROVAL
Signature of Office Director/Regional Administrator

Signature Date

Signature of Deputy Director, OIP (if required)

Signature Date

Signature of Chairman (if required)

Signature Date

NRC FORM 445 (MM-YYYY)

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 445
(MM-YYYY)
NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)
C. TRAVEL ITINERARY

Date

Location
(City, Country)

Contact on Site
(Name, telephone number, and e-mail address)

Activity

"X" If
Classified

D. FUNDING
Source of Funding

NRC FORM 445 (MM-YYYY)

Job Code

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 445
(MM-YYYY)
NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)
PRIVACY ACT STATEMENT
NRC FORM 445
REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the following statement
is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 445. This
information is maintained in a system of records designated as NRC-20 and described at 81 Federal Register 81334-81335 (November
17, 2016), or the most recent Federal Register publication of the NRC's “Republication of Systems of Records Notices” located in the
NRC's Agencywide Documents Access and Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter 61; 41 CFR 102-118;
Executive Order (E.O.) 9397, as amended by E.O. 13478.
2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.
3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may disclose
information from this system of records to the U.S. Treasury for payment; the Department of State or an embassy for passports or
visas; the General Services Administration and the Office of Management and Budget for required periodic reporting; the charge card
issuing bank; the Department of Interior, National Business Center, for collecting severe travel card delinquencies by employee salary
offset; and to a consumer reporting agency to obtain credit reports. The information may also be disclosed to an appropriate Federal,
State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an
administrative or judicial proceeding; 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
under a protective order issued by a court of competent jurisdiction, and in presenting evidence; 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, on a need-to-know basis;
and 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.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT
PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided approval for foreign travel
may be denied.
5. SYSTEM MANAGER AND ADDRESS: Chief, Travel Operations Branch, Division of the Controller, Office of the Chief Financial
Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001. For passport and visa records: Chief, International
Operations Branch, Office of International Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

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