974 Privacy Act Complaints, Concerns, or Questions Form

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 974

(MM-DD-YYYY)

PRIVACY ACT COMPLAINTS,
CONCERNS OR QUESTIONS FORM
Name (Last, First, and Middle Initial)

APPROVED BY OMB: NO. 3150-XXXX

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this voluntary information collection request: 15 minutes. This information is
required by the National Institute of Science and Technology (NIST) Special Publication 800-53 Revision 5, Security and
Privacy Controls for Information Systems and Organizations. The Nuclear Regulatory Commission (NRC) is providing an
electronic mechanism for the public to voluntarily register complaints, concerns or questions regarding data collection
practices at the NRC. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch
(T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by email to
Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150XXXX), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email:
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.

Telephone Number

Email Address

Provide summary of complaint or a written description of the specific circumstances.

Provide a summary of the actions you or the NRC has taken to resolve this complaint.

Provide the preferred method of contact regarding your complaint (i.e., mailing address, email address, phone number)

Note: NRC will send acknowledgement within 10 business days of receipt of your complaint.
Signature and Date

NRC Form 974 (MM-DD-YYYY)

Submit by Email