Information Collection

NRC Form 4 (3150-0005 Agreement State Licensee RK)

IC 44866 under ICR 200607-3150-006 · OMB 3150-0233.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NRC Form 4 NRC Form 4 (3150-0005 Agreement State Licensee RK)	Form and Instruction
NRC Form 4 Cumulative Occupational Dose History Nrc4.pdf www.nrc.gov/reading-rm/doc-collections/forms/nrc4.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 4	Cumulative Occupational Dose History	Nrc4.pdf	http://www.nrc.gov/reading-rm/doc-collections/forms/nrc4.pdf	No		Fillable Fileable

Line of Business: Health

Subfunction:

Privacy Act System of Records

Title: NRC-27

FR Citation: 69 FR 57601

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	3,348	3,348

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.