NRC Form 4, Cumulative Occupational Exposure History

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0005 can be found here:

Documents and Forms

Document Name Document Type
Form NRC 4 NRC Form 4, Cumulative Occupational Exposure History Form
NRC 4 NRC Form 4, Cumulative Occupational Dose History Nrc4.pdf www.nrc.gov/reading-rm/doc-collections/forms/nrc4.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NRC Form 4, Cumulative Occupational Exposure History	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 19

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NRC 4	NRC Form 4, Cumulative Occupational Dose History	Nrc4.pdf	http://www.nrc.gov/reading-rm/doc-collections/forms/nrc4.pdf	No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 227	Number of Respondents for Small Entity: 25

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	24,335	-17	24,352
Annual IC Time Burden (Hours)	3,332	-8,844	12,176
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.