Form DOE F 470.3 DOE F 470.3 Human Reliability Program (HRP) Certification

CUI//PRVCY
when filled in
DOE F 470.3 (06/2023)

PREVIOUS EDITIONS ARE OBSOLETE

U.S. DEPARTMENT OF ENERGY
HUMAN RELIABILITY PROGRAM (HRP)
CERTIFICATION

OMB Control No. 1910-5122
Expiration Date:

PRIVACY ACT STATEMENT
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the
U.S. Department of Energy (DOE) to regulate the possession and use of special nuclear material and access to
restricted data. DOE will use the information collected on this form to aid in the determination of an individual’s
eligibility for an HRP certification. The information may also be provided to other agencies of the United States
government for investigations that involve protection of the national security, public health and safety, or the
environment. Submission of the information requested on this form is voluntary, but failure to provide the
information may result in denial of an HRP certification. If DOE uses the information for purposes other than
those indicated in this statement, it will provide notice of those additional purposes to persons who have submitted
information on this form. This statement is in reference to the relevant System of Records Notice (SORN) per Circular

A-108, DOE-50, HRP Records SORN 230104 (https://www.federalregister.gov/documents/2009/01/09/E8-31316/privacyact-of-1974-publication-of-compilation-of-privacy-act-systems-of-records).

OMB BURDEN DISCLOSURE STATEMENT
This data is being collected to certify participation in the Human Reliability Program. The data you supply
will be used to ensure that individuals who occupy positions affording access to certain materials, nuclear
explosive devices, facilities, and programs meet the highest standards of reliability and physical and mental
suitability. Public reporting burden for this collection of information is estimated to average 10 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering, and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development &
Implementation Office, IM-22, Information Collection Management Program (1910-5122), U.S. Department
of Energy, 1000 Independence Ave., SW, Washington, DC 20585; and to the Office of Management and
Budget (OMB), OIRA, Paperwork Reduction Project (1910-5122), Washington, DC 20503. Notwithstanding
any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid OMB control number. Submission of this
data is mandatory.
SECTION I: PARTICIPANT INFORMATION
1. Name:
Initial: _____
Annual: _____
2. Position:

3. Employer:

4. Anniversary Due Date:

5. Drug Testing Date:

6. Alcohol Testing Date:

7. Training Completion Date:

8. Counterintelligence Evaluation Approval Date:
SECTION II: SUPERVISORY REVIEW AND APPROVAL
I have reviewed all available information regarding this individual and have no reason to believe that this
individual may represent a security or safety concern. (If you cannot make such an affirmation, then do not sign
here, and attach a signed explanation.)
9. Name:

DOE F 470.3 (06/2023)

10. Signature:

11. Date:

Section 508 Compliant

CUI//PRVCY
when filled in

DOE F 470.3 (06/2023)

PREVIOUS EDITIONS ARE OBSOLETE

OMB Control No. 1910-5122
Expiration Date:

SECTION III: MEDICAL ASSESSMENT
I have reviewed this individual’s medical files (including the examining physician’s medical report and
psychological evaluation) and I have no reason to believe that this individual may represent a security or safety
concern. (If you cannot make such an affirmation, then do not sign here, and attach a signed explanation.)
Site Occupational Medical Director Approval
12. Name:
13. Signature:
14. Date:

15. Name:

HRP Designated Physician Approval (Optional)
16. Signature:

17. Date:

SECTION IV: MANAGEMENT OFFICIAL EVALUATION AND APPROVAL
All relevant information concerning this individual (including the results of drug and alcohol testing) has been
reviewed, and I have no reason to believe that this individual may represent a security or safety concern;
therefore, I recommend that this individual be reviewed for HRP certification. (If you cannot make such an
affirmation, then do not sign here, and attach a signed explanation.)
18. Name:

19. Signature:

20. Date:

SECTION V: DOE PERSONNEL SECURITY REVIEW AND APPROVAL
☐ Recommend HRP certification be granted/continued

☐ Recommend remanding for further clarifying information.
☐ Process under 10 CFR 710
21. Name:

22. Signature:

23. Date:

SECTION VI: HRP CERTIFICATION DETERMINATION AND APPROVAL
☐ HRP certification granted/continued.

☐ HRP certification temporarily removed.

☐ HRP certification reinstated.
☐ HRP certification revoked.
24. Name:

DOE F 470.3 (06/2023)

25. Signature:

Page 2 of 2

26. Date:

Section 508 Compliant