NRC Form 176 - Security Acknowledgment and Termination Statement

Forms and Documents

Document Name	Status
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction	New
30-day published FRN- NRC Form 176.doc Supplementary Document	2019-07-09
NRC Form 176- Final Supporting Statement.pdf Supporting Statement A	2019-07-09

IC Document Collections

IC ID	Document Title	Status
236852	NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction	New

ICR Details

OMB Control No: 3150-0239	ICR Reference No: 201907-3150-004
Status: Active	Previous ICR Reference No:
Agency/Subagency: NRC	Agency Tracking No:
Title: NRC Form 176 - Security Acknowledgment and Termination Statement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/24/2019
	Date Received in OIRA: 07/11/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved
Responses	400	0	0
Time Burden (Hours)	80	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The NRC Form 176, “Security Acknowledgment and Termination Statement” is completed by employees, licensees and contractors in connection with the termination of their access authorization/security clearance granted by the NRC and to acknowledgment and accept their continuing security responsibility.

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Authorizing Statute(s): EO: EO 12958 Name/Subject of EO: Section 4.3
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 13976	04/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 32480	07/08/2019
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 176, Security Acknowledgment and Termination Statement.	NRC Form 176	SECURITY ACKNOWLEDGMENT

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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	400	0	0	0	400	0
Annual Time Burden (Hours)	80	0	0	0	80	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 NRC Form 136, “Security Termination Statement” and NRC Form 176, “Security Acknowledgment,” is now combined into one form. The new form will be titled NRC Form 176, “Security Acknowledgement and Termination Statement.” Modification to the form consisted of adding from the NRC Form 136, “Security Termination Statement” number 3 and 4 to the new NRC Form 176, “Security Acknowledgment and Termination Statement,” where they became number 5 and 6 on the form. The last four SSN field has been added to the new NRC Form 176 on page 1 and page 4 next to the date. Replaced unclassified safeguards information within the form with Controlled Unclassified Information. Security Debriefing Acknowledgement was added on the pages for the need of a signature. The cost has increased due to a change in the fee rate from $268/hr. to $275/hr.

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Annual Cost to Federal Government: $22,053

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 07/11/2019

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