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

DOE F 470.3 (07/03)
Replaces DOE F 5631.35
All other editions obsolete.

OFFICIAL USE ONLY

OMB Control No. 1910-5122

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

INITIAL [ ]

ANNUAL [ ]

POSITION:_____________________________

DRUG TESTING DATE:___________________

EMPLOYER:___________________________

ALCOHOL TESTING DATE:_______________

ANNIVERSARY/DUE DATE:_____________

TRAINING COMPLETION DATE:__________

COUNTERINTELLIGENCE EVALUATION APPROVAL DATE:
__________________________________
SECTION A - SUPERVISORY REVIEW
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.)
SUPERVISOR:_________________________________________________________ DATE:_____________
SECTION B - 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:___________________________ DATE:_____________
SECTION C - MANAGEMENT EVALUATION
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.)
MANAGEMENT OFFICIAL:____________________________________________

DATE:_____________

OFFICIAL USE ONLY
May be exempt from public release under the Freedom
of Information Act (5 U.S.C. 552) Exemption (b)(6), Personal
Privacy. Department of Energy review required before public release
Name/Org: _____________________________Date:___________
OFFICIAL USE ONLY
(when shaded area filled in)

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DOE F 470.3 (07/03)
Replaces DOE F 5631.35
All other editions obsolete.

OFFICIAL USE ONLY

OMB Control No. 1910-5122

U.S. DEPARTMENT OF ENERGY
HUMAN RELIABILITY PROGRAM (HRP)
CERTIFICATION
SECTION D - DOE PERSONNEL SECURITY REVIEW
[ ] Recommend HRP certification be granted/continued.
[ ] Recommend remanding for further clarifying information.
[ ] Process under 10 CFR 710.
PERSONNEL SECURITY SPECIALIST:__________________________________

DATE:_____________

SECTION E - HRP CERTIFICATION DETERMINATION
[ ] HRP certification granted/continued.
[ ] HRP certification temporarily removed.
[ ] HRP certification reinstated.
[ ] HRP certification revoked.
HRP CERTIFYING OFFICIAL:__________________________________________ DATE:_____________

OBM Disclosure Statement
Public reporting burden for this collection of information is estimated to average six 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 Business and Information Management, IM-10, GTN,
Paperwork Reduction Project (1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 205851290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-5122), Washington, DC 20503.

OFFICIAL USE ONLY
(when shaded area filled in)

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