Information Collection

NRC Form 4, Cumulative Occupational Exposure History

IC 33127 under ICR 200612-3150-001 · OMB 3150-0005.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.