Form NRC Form 5 NRC Form 5 Occupational Dose Record for a Monitoring Period

OF

PAGE

NRC FORM 5

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)
10 CFR PART 20

OCCUPATIONAL DOSE RECORD
FOR A MONITORING PERIOD
*Note: Social Security Numbers must not be visible on the outside of any package sent by mail.
1. NAME (LAST, FIRST, MIDDLE INITIAL)

APPROVED BY OMB NO. 3150-0006

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 20 minutes. This information is used to ensure that
doses to individual do not exceed regulatory limits. This information is required to record/annually report individual occupational
exposure to radiation to ensure that the exposure does not exceed regulatory limits. Send comments regarding burden estimate to the
Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to
Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-xxxx), Attn: Desk
Officer for the Nuclear Regulatory Commission, 725 17 Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov.
The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document
requesting or requiring the collection displays a currently valid OMB control number.

2. IDENTIFICATION NUMBER*

3. ID TYPE

4. SEX

5. DATE OF BIRTH
(MM/DD/YYYY)

MALE
FEMALE

7. LICENSEE NAME

6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)

8. LICENSE NUMBER(S)

9A.

-

9B.

ESTIMATE

INTAKES
10A. RADIONUCLIDE

RECORD

10B. CLASS

10C. MODE

DOSES (in rem)

10D. INTAKE IN µCi
EFFECTIVE DOSE EQUIVALENT
(FOR EXTERNAL EXPOSURES)

(EDEX) 11A.

DEEP DOSE EQUIVALENT
(FOR THE ENTIRE MONITORING PERIOD)

(DDE) 11B.

LENS (EYE) DOSE EQUIVALENT

(LDE) 12.

SHALLOW DOSE EQUIVALENT,
WHOLE BODY

(SDE,WB) 13.

SHALLOW DOSE EQUIVALENT,
MAX EXTREMITY

(SDE,ME) 14.

COMMITTED EFFECTIVE
DOSE EQUIVALENT
COMMITTED DOSE EQUIVALENT,
MAXIMALLY EXPOSED ORGAN

(CEDE) 15.
(CDE) 16.

TOTAL EFFECTIVE DOSE EQUIVALENT
(ADD BLOCKS 11A AND 15)

(TEDE) 17.

TOTAL ORGAN DOSE EQUIVALENT MAX ORGAN
(ADD BLOCKS 11B AND 16)

(TODE) 18.

19. COMMENTS

20. SIGNATURE - LICENSEE

NRC FORM 5 (MM-YYYY)

21. DATE PREPARED

ROUTINE
PSE

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 5
(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).

10A. Enter the symbol for each radionuclide that
resulted in an internal exposure recorded for
the individual, using the format "Xx-###x," for
instance Cs-137 or Tc-99m.

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.

10B. Enter the lung clearance class as listed in
Appendix B to 10 CFR Part 20.1001-2401 (D, W,
Y, V, F, M, S, or O for other) for all intakes by
inhalation.

3.

Enter the code for the type of identification used
as shown below:

10C. Enter the mode of intake. For inhalation, enter
"H." For absorption through the skin, enter "B."
For oral ingestion, enter "G." For injection,
enter "J."

CODE ID TYPE

10D. Enter the intake of each radionuclide in µCi.

SSN

U.S. Social Security Number

11A. Enter the effective dose equivalent (EDEX).

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.

8.

Enter the NRC license number or numbers.

9A. Place an “X” in Record, or Estimate. 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.
9B. 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. If more
than one PSE was received in a single year, the licensee
should sum them and report the total of all PSEs.

11B. DDE – Enter the DDE measured at the highest
point on the whole body for the entire monitoring
period (e.g.,year – including those time periods
when EDEX was being determined using NRCapproved special dosimetry methods).
12.

Enter the lens does 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 11A and 15.

18.

Enter the total organ dose equivalent (TODE) for
the maximally exposed organ. The TODE is the
sum of items 11B and 16.

19.

COMMENTS: In the space provided, enter
additional information that might be needed to
determine compliance with limits. An example
might be to enter the note that the SDE,ME was
the result of exposure from a discrete hot particle.
Another possibility would be to indicate that an
over exposed report has been sent to NRC in
reference to the exposure report.

20.

Signature of the person designated to represent
the licensee.

21.

Enter the date this form was prepared.

PRIVACY ACT STATEMENT
NRC FORM 5
OCCUPATIONAL DOSE RECORD FOR A MONITORING PERIOD
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 5. This information is maintained in a system of records designated as
NRC-27 and described at 81 Federal Register 81340 (November 17, 2016), or the most recent Federal
Register publication of the NRC's Systems of Records Notices that is located in NRCs 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 Parts 20 and 34; Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O. 12196, as
amended; E.O. 13708.
2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the risk of exposures to
radiation and radioactive materials associated with licensed activities 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): In addition to the disclosures permitted under subsection (b) of the Privacy Act, this
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; or 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 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; 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.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF
NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information, including the
Social Security number (SSN) in block #2. The SSN is used to assure that NRC has an accurate and unique
identifier not subject to the coincidence of similar names or birth dates among the large number of persons on
who data is maintained. The licensee must complete NRC Form 5 on each individual for whom personnel
monitoring is required under 10 CFR 20.1502. In addition, licensees must submit this information to NRC in
accordance with the requirement under 10 CFR 20.2206. Failure to do so may subject the licensee to
enforcement action in accordance with 10 CFR 20.2401.

5. SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection
Branch, Division of Systems Analysis, Office of Nuclear Regulatory Research, U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001.