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NRC FORM 4
U.S. NUCLEAR REGULATORY COMMISSION
(MM-YYYY)
10 CFR PART 20
CUMULATIVE OCCUPATIONAL DOSE HISTORY
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
APPROVED BY OMB NO. 3150-0005
EXPIRES: MM/DD/YYYY
Estimated burden per response to comply with this mandatory information collection request: 30
minutes. The record is used to ensure that doses to individuals do not exceed regulatory limits. This
information is required to record an individual's lifetime occupational exposure to radiation to ensure
that the cumulative exposure to radiation does not exceed regulatory limits. Send comments
regarding the burden estimate to the Records and FOIA/Privacy Services Branch (T-5 F52), U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001, or by Internet e-mail to
[email protected] , and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB10202, (3150-0005), Office of Management and Budget, Washington, DC 20503. If a means used
to impose an information collection does not display a currently valid OMB control number, the NRC
may not conduct or sponsor, and a person is not required to respond to, the information collection.
3. ID TYPE
MALE
4. SEX
5. DATE OF BIRTH
(MM/DD/YYYY)
FEMALE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
6. MONITORING PERIOD
13. SDE, WB
14. SDE, ME
7. LICENSEE NAME
15. CEDE
16. CDE
8. LICENSE NUMBER
17. TEDE
9.
PSE
18. TODE
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
6. MONITORING PERIOD
13. SDE, WB
14. SDE, ME
7. LICENSEE NAME
15. CEDE
16. CDE
8. LICENSE NUMBER
17. TEDE
9.
PSE
18. TODE
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
6. MONITORING PERIOD
13. SDE, WB
14. SDE, ME
7. LICENSEE NAME
15. CEDE
16. CDE
8. LICENSE NUMBER
17. TEDE
9.
PSE
18. TODE
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
6. MONITORING PERIOD
13. SDE, WB
14. SDE, ME
7. LICENSEE NAME
15. CEDE
16. CDE
8. LICENSE NUMBER
17. TEDE
9.
PSE
18. TODE
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
6. MONITORING PERIOD
13. SDE, WB
14. SDE, ME
7. LICENSEE NAME
15. CEDE
16. CDE
8. LICENSE NUMBER
17. TEDE
9.
PSE
18. TODE
RECORD
10.
ROUTINE
ESTIMATE
NO RECORD
11. DDE
12. LDE
19. SIGNATURE OF MONITORED INDIVIDUAL
NRC FORM 4 (MM-YYYY)
13. SDE, WB
14. SDE, ME
20. DATE SIGNED
21. CERTIFYING ORGANIZATION
15. CEDE
16. CDE
17. TEDE
22. SIGNATURE OF DESIGNEE
PSE
18. TODE
23. DATE SIGNED
PRINTED ON RECYCLED PAPER
INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 4
(All doses should be stated in rems)
1.
Type or print the full name of the monitored
individual in the order of last name (include "Jr,"
"Sr," "III," etc.), first name, middle initial (if
applicable).
2.
Enter the individual's identification number,
including punctuation. This number should be the
9-digit social security number if at all possible. If
the individual has no social security number, enter
the number from another official identification such
as a passport or work permit.
3.
Enter the code for the type of identification used as
shown below:
10.
Place an "X" in either Routine or PSE. Choose
"Routine" if the data represent the results of
monitoring for routine exposures. Choose "PSE" if
the listed dose data represents the results of
monitoring of planned special exposures received
during the monitoring period.
11.
Enter the deep dose equivalent (DDE) to the whole
body.
12.
Enter the eye dose equivalent (LDE) recorded for
the lens of the eye.
13.
Enter the shallow dose equivalent recorded for the
skin of the whole body (SDE,WB).
14.
Enter the shallow dose equivalent recorded for the
skin of the extremity receiving the maximum dose
(SDE,ME).
15.
Enter the committed effective dose equivalent
(CEDE).
Check the box that denotes the sex of the
individual being monitored.
16.
Enter the committed dose equivalent (CDE)
recorded for the maximally exposed organ.
5.
Enter the date of birth of the individual being
monitored in the format MM/DD/YYYY.
17.
Enter the total effective dose equivalent (TEDE).
The TEDE is the sum of items 11 and 15.
6.
Enter the monitoring period for which this report is
filed. The format should be MM/DD/YYYY MM/DD/YYYY.
18.
Enter the total organ dose equivalent (TODE) for
the maximally exposed organ. The TODE is the
sum of items 11 and 16.
7.
Enter the name of the licensee or facility not
licensed by NRC that provided monitoring.
19.
8.
Enter the NRC license number or numbers.
Signature of the monitored individual. The
signature of the monitored individual on this form
indicates that the information contained on the form
is complete and correct to the best of his or her
knowledge.
9.
Place an "X" in Record, Estimate, or No Record.
Choose "Record" if the dose data listed represent a
final determination of the dose received to the best
of the licensee's knowledge. Choose "Estimate"
only if the listed dose data are preliminary and will
be superseded by a final determination resulting in
a subsequent report. An example of such an
instance would be dose data based on self-reading
dosimeter results and the licensee intends to
assign the record dose on the basis of TLD results
that are not yet available. If the individual or an
organization has indicated that the individual was
monitored, but the monitoring records could not be
obtained, enter “No Record” for this monitoring
period. The individual would not be available for a
PSE. For monitoring periods during the current
year where records are not available, reduce the
individual’s allowable dose by 1.25 rems for each
quarter for which records were unavailable as
required by 10 CFR 20.2104(e)(1).
20.
Enter the date this form was signed by the
monitored individual.
21.
[OPTIONAL] Enter the name of the licensee or
facility not licensed by NRC, providing monitoring
for exposure to radiation (such as a DOE facility) or
the employer if the individual is not employed by the
licensee and the employer chooses to maintain
exposure records for its employees.
22.
[OPTIONAL] Signature of the person designated to
represent the licensee or employer entered in item
21. The licensee or employer who chooses to
countersign the form should have on file
documentation of all the information on the NRC
Form 4 being signed.
23.
[OPTIONAL] Enter the date this form was signed by
the designated representative.
CODE
SSN
PPN
CSI
WPN
PADS
OTH
4.
ID TYPE
U.S. Social Security Number
Passport Number
Canadian Social Insurance Number
Work Permit Number
PADS Identification Number
Other
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy
Act of 1974 (Public Law 93-579), the following statement is furnished to
individuals who supply information to the U.S. Nuclear Regulatory
Commission (NRC) on NRC Form 4. This information is maintained in a
system of records designated as NRC-27 and described at 67 Federal
Register 63793 (October 15, 2002), or the most recent Federal Register
publication of the NRC's "Republication of Systems of Records Notices" that
is available at the NRC Public Document Room, 11555 Rockville Pike,
Rockville, Maryland or located in NRC’s Agencywide Documents Access and
Management System (ADAMS).
1.
AUTHORITY: 42 U.S.C. 2073, 2093, 2095, 2111, 2133, 2134, and
2201(o) (1992); 10 CFR 20.2106, 20.2201-20.2204, and 20.2206 (2002);
Executive Order 9397, November 22, 1943.
2.
PRINCIPAL PURPOSE(S): The information is used by the NRC in its
evaluation of the risk of radiation exposure associated with the licensed
activity and in exercising its statutory responsibility to monitor and
regulate the safety and health practices of its licensees. The data
permits a meaningful comparison of both current and long-term
exposure experience among types of licensees and among licensees
within each type. Data on your exposure to radiation is available to you
upon your request.
3.
ROUTINE USE(S): The information may be used to provide data to
other Federal and State agencies involved in monitoring and/or
evaluating radiation exposure received by individuals monitored for
radiation exposure while employed by or visiting or temporarily assigned
to certain NRC licensed facilities; to return data provided by licensee
upon request. The information may also be disclosed to an appropriate
Federal, State, local or Foreign agency in the event the information
indicates a violation or potential violation of law and in the course of an
administrative or judicial proceeding. In addition, this information may
be transferred to an appropriate Federal, State, local and Foreign
agency to the extent relevant and necessary for an NRC decision about
you or to the extend relevant and necessary for that agency's decision
about you. Information from this form may also be disclosed, in the
course of discovery and in presenting evidence, to a Congressional
office to respond to their inquiry made at your request, or to NRC-paid
experts, consultants, and others under contract with the NRC, on a
need-to-know basis.
4.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND
EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: It is
voluntary that you furnish the requested information, including social
security number (identification number). The social security number is
used to assure that NRC has an accurate identifier not subject to the
coincidence of similar names or birth dates among the large number of
persons on who data is maintained and to assure that there are no
missed doses or monitoring periods and an individual gets a complete
dose history when requested. The licensee must complete NRC Form 5
on each individual for whom personnel monitoring is required under 10
CFR 20.2106. Failure to do so may subject the licensee to enforcement
action in accordance with 10 CFR 20.2401.
5.
SYSTEM MANAGER(S) AND ADDRESS: REIRS Project Manager,
Radiation Protection, Environmental Risk, and Waste Management
Branch, Division of Systems Analysis and Regulatory Effectiveness,
Office of Nuclear Regulatory Research, U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001.
| File Type | application/pdf |
| File Title | O:\WP\Nrc4.wpd |
| File Modified | 2004-05-19 |
| File Created | 2004-05-19 |