30-day Supporting Statement ML22158A099 (1)

FINAL SUPPORTING STATEMENT FOR NRC FORM 176
“SECURITY ACKNOWLEDGMENT AND TERMINATION STATEMENT”
(3150-0239)
Extension
Description of the Information Collection
The reporting requirements associated with the U.S. Nuclear Regulatory Commission
(NRC) Form 176, "Security Acknowledgement and Termination Statement," affect the NRC
employees, licensees, and contractors who have been granted an NRC access
authorization (security clearance). When an applicant requires an NRC access
authorization, he/she shall sign the NRC Form 176 prior to access to Restricted Data,
Controlled Unclassified Information, and/or Special Nuclear Materials. When the NRC
access authorization is no longer required, the employee or contractor acknowledges and
accepts his/her continuingsecurity responsibilities, as stated on the NRC Form 176, by
signing the form.
The NRC Form 176 requires a minimum amount of personal information (e.g., name, date of
termination, last four digits of social security number, and name the person providing the
briefing). The form is countersignedby an Office of Administration, Division of Facilities and
Security (DFS) employee, or representative of the licensee or contractor who administered
the completion of the form by the employee, licensee, or contractor.
There is no recordkeeping requirement for the NRC employee, licensee, or contractor since
the completedNRC Form 176 is to be forwarded to NRC headquarters, DFS for retention in the
individual's Personnel Security File (PSF). The established retention period of the PSF is
destroyed upon notification of death or 5 years after termination of the last access authorization
held.
The use of this form affords some assurance that access to classified information, Restricted
Data (as defined by Section 11.y. of the Atomic Energy Act of 1954 (42 U.S.C. § 2014)),
Controlled Unclassified Information (as defined by 32 C.F.R. Part 2002 Controlled
Unclassified Information), and special nuclear material, as well as the knowledge gained by
the respondent will be properly protected, and therefore, benefits the NRC security program
and public at large.
A.

JUSTIFICATION
1.

Need for and Practical Utility of the Information Collection
Section 4.3 of Executive Order (E.O.) 12958 requires agencies to establish
controls over the distribution of classified information to assure that it is
distributed only to organizations or individuals eligible for access who also
have a need-to-know the information. When an applicant requires an NRC
access authorization, he/she shall sign the NRC Form 176 prior to access to
Restricted Data, Controlled Unclassified Information, and/or Special Nuclear

Materials. When an individual with access to classified information, Restricted
Data, Controlled Unclassified Information and/or special nuclear material is
no longer employed in aposition requiring access to such
information/material, the NRC will terminate the individual’s access
authorization in accordance with 10 CFR 25.33 (applicable to licensees) or in
accordance with 10 CFR Part 10 and NRC Management Directive (MD) 12.3,
“NRC Personnel Security Program” (applicable to NRC employees and
contractors). The NRC Form 176 is an integral part of reminding individuals of
their continuing responsibilities after termination of service.
2.

Agency Use of Information
As stated in MD 12.3 (for employees and contractors) and in 10 CFR 25.33
(for licensees), the completed NRC Form 176 is to be forwarded by the
employee/licensee/contractor to NRCheadquarters for use by DFS in
connection with the security acknowledgment and termination of the
respondent’s employment with the NRC. In addition to providing assurance
of NRC compliance with E.O. 12958, the NRC Form 176 is the vehicle used
by DFS to apprise the individual of his/her continuing responsibilities for
protecting classified information, RestrictedData, and Controlled Unclassified
Information that he/she had access to, in the course of performing official
duties. The individual’s signature on this form indicates their
acknowledgment/acceptance of these continuing responsibilities.

Failure to use the NRC Form 176 by the licensee/contractor may result
in: (1) failure to properly investigate an applicant for the appropriate
access authorization; (2) failure to terminate the NRC access
authorization when circumstances dictate and, therefore, unnecessary
continued access to classified information, Restricted Data, and/or
ControlledUnclassified Information; and (3) the individual not being
apprised of, or officially acknowledging (by signature) his/her continuing
responsibilities for protecting classified information, Restricted Data,
and/or Controlled Unclassified Information.
3.

Reduction of Burden Through Information Technology
The NRC has issued Guidance for Electronic Submissions to the NRC which
provides direction for the electronic transmission and submittal of documents
to the NRC. Electronic transmission and submittal of documents can be
accomplished via the following avenues: the Electronic Information Exchange
(EIE) process, which is available from the NRC's “Electronic Submittals” Web
page, by facsimile orby e-mail. It is estimated that approximately less than
30% of the responses are filed electronically.

4.

Effort to Identify Duplication and Use Similar Information
No sources of similar information are available. There is no duplication of
requirements.

5.

Effort to Reduce Small Business Burden

The burden associated with this form is minimal. There is no
significant burden on acontractor that is a small business enterprise
or entity.
6.

Consequences to Federal Program or Policy Activities if the Collection
is not Conductedor is Conducted Less Frequently
The frequency of information collection is limited to circumstances when the
respondent’s NRC service is to be investigated for access authorization and
approved access authorization needs to be terminated. In most cases, an
individual will need to sign the NRC Form 176 twice. If the information is not
collected, the assurance that only appropriately cleared individuals have
access to classified information is reduced. Furthermore, it is likely that
individuals will be unaware of their continued responsibility to protect
classified information. Thus, less frequent collection may endanger the United
States common defense and nationalsecurity.

7.

Circumstances Which Justify Variation from the Office of
Management and Budget(OMB) Guidelines
There is no variation from OMB Guidelines in the collection of information.

8.

Consultations outside the NRC
Opportunity for public comment on the information collection requirements for
this clearance package was published In the Federal Register on April 6, 2022
(87 FR 19982). The respondents that were contacted include, two licensees
and two individuals that work in the Office of the Chief Human Capital Officer at
the U.S. Nuclear Regulatory Commission. They were contacted as part of the
consultation process and the method used to contact them was by courtesy call
and email. One individual provided a response as “yes, no and no
suggestions” to the consultations. All other individuals from the public did not
respond and no public comments were received.

9.

Payment or Gift to Respondents
Not Applicable.

10.

Confidentiality of the Information
Confidential and proprietary information is protected in accordance with NRC
regulations at 10 CFR 9.17(a) and 10 CFR 2.390(b). However, no information
normally considered confidentialor proprietary is requested.
Personal Information provided on the NRC Form 176 is handled and
protected in accordance with NRC directives and provisions of the Privacy
Act of 1974, as described inthe Privacy Act Statement on the form.
Information is maintained in a system of records designated as NRC-39 and

described in the Federal Register in NRC’s “Personnel Security Files and
Associated Records” on December 27, 2019, (84 FR 71568).
11.

Justification for Sensitive Questions
There is no sensitive information requested on the NRC Form 176.

12.

Estimated Burden and Burden Hour Cost
The $288 hourly rate used in the burden estimates is based on the Nuclear
Regulatory Commission’s fee for hourly rates as noted in 10 CFR 170.20
“Average cost per professional staff-hour.” For more information on the basis
of this rate, see the Revision of Fee Schedules;Fee Recovery for Fiscal Year
2018 (83 FR 29622, June 25, 2018).
An estimated 12 minutes (based on staff experience) is required to
complete each NRC Form 176. The NRC staff estimates that 400
responses will be received annually, resultingin a total of annual burden to
the public of 80 hours (400 responses x 12 minutes / 60). The estimated
annual cost is $23,040 (80 hours x $288 per hour).
NOTE: There is no record keeping requirement for
contractors/licensees to maintain acopy of the NRC Form 176.

13.

Estimate of Other Additional Costs
There are no additional costs.

14.

Estimated Annualized Cost to the Federal Government
The staff has developed estimates of cost to the Federal Government related
to the conduct ofthis information collection. These estimates are based on
staff experiences and subject matterexpertise and include the burden needed
to review, analyze, and process the collected information and any relevant
operational expenses.
The estimated annual cost to the Federal Government associated with the
NRC Form 176 is $23,040. The cost was computed as follows:
Total effort 400 forms X 12 minutes = 4800/60 = 80 hrs. X $288/hr.) =
$23,040.00
Annual record holding
(1/4 cubic (cu) foot (ft.) X $212/cu. ft.)

=

Total estimated annual cost to Federal government =

$ 53.00
$23,040

This cost is fully recovered through fee assessment to NRC licensees
pursuant to 10 CFRParts 170 and/or 171.

15.

Reasons for Changes in Burden or Cost
The NRC Form 176, “Security Acknowledgment and Termination Statement”
has now added the "Typed or Printed Employee Name" section to the NRC
Form 176C page. This page is used when departing people are debriefed.
NRC modified the form to include a print name field in addition to the signature
field for clarity. There is no change in the burden required to complete the
form. The cost has increased due to a change in the fee rate from $275/hr. to
$288/hr.

16.

Publications for Statistical Use
There is no application of statistics in the information collections related to
NRC Form 176 and no publication of the information.

17.

Reason for Not Displaying the
Expiration Date
The expiration date is
displayed on the form.

18.

Exceptions to the
Certification Statement
Not Applicable.