10 CFR Part 4 Questionnaire

IDENTIFYING INFORMATION

Name of Applicant:

Application for:

Date Compliance Review Inquiry Completed:

PART A

SBCR Compliance Review

APPROVED BY OMB: NO. 3150-0053

EXPIRES: 08/31/2007

Estimated burden per response to comply with this mandatory collection request: 1 hour (30 minutes each for Parts A and B). The information is required by NRC to process payments to contractors. Send comments regarding burden estimate to the Records and FOIA/Privacy Service 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, NEOB‑10202, (3150-0053), 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.

PLEASE RESPOND TO ALL INQUIRIES,

AND SUBMIT APPLICABLE INFORMATION AND DOCUMENTATION TO

SBCR VIA [email protected], OR FAX: 301-415-5953,

ATTENTION: Bruce Currie, J.D., Program Coordinator

Contact Number: 301-415-5988

Please provide brief responses to the following inquiries. Where applicable forward all related documentation to SBCR:

1. Program/Contract Services: Identify the manner in which services are or will be provided, and data/information necessary for determining whether any persons are or will be denied such services on the basis of prohibited discrimination.

2. Program/Contract Population Served: Identify the geographic location(s) where program activities/services will be provided:

• Headquarters (Washington Metropolitan areas)

• Region I King of Prussia, Pennsylvania or surrounding areas

• Region II Atlanta, Georgia or surrounding areas

• Region III Lisle, Illinois or surrounding areas

• Region IV Arlington, Texas or surrounding areas

• Other, Specify

3. Limited English Proficiency: Provide information/data regarding EEO coverage, including use or planned use of bilingual public-contact employees serving beneficiaries of the program where necessary to permit effective participation by beneficiaries unable to speak or understand English.

4. Facilities and/or Locations: Identify the location(s) of existing or proposed facilities connected with the program/services, and related information adequate for determining whether the location has or will have the effect of unnecessarily denying access to any persons on the basis of prohibited discrimination.

5. Organizational Membership: Identify the present or proposed membership, by race, color and national origin, in any planning or advisory body which is an integral part of the program/service.

6. Changes in Location: If applicable, identify where relocation is involved, the requirements and steps used or proposed to guard against unnecessary impact on persons in the protected classes identified in Question number 2.

IDENTIFYING INFORMATION

Name of Applicant:

Application for:

Date Compliance Review Inquiry Completed:

PART B

SBCR Compliance Review

APPROVED BY OMB: NO. 3150-0053

EXPIRES: 08/31/2007

Estimated burden per response to comply with this mandatory collection request: 1 hour (30 minutes each for Parts A and B). The information is required by NRC to process payments to contractors. Send comments regarding burden estimate to the Records and FOIA/Privacy Service 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, NEOB‑10202, (3150-0053), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currentlyvalid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

PLEASE RESPOND TO ALL INQUIRIES,

AND SUBMIT APPLICABLE INFORMATION AND DOCUMENTATION TO

SBCR VIA [email protected], OR FAX: 301-415-5953,

ATTENTION: Bruce L. Currie, J.D., Program Coordinator

1. Promptly notify NRC/SBCR upon its request of any lawsuit filed against the applicant or recipient alleging discrimination on the basis of race, sex, color, national origin, disability, religion, age, sexual orientation, or status as a parent.

In Agreement: Yes No

2. Notify NRC/SBCR upon its request of any complaints filed against the recipient alleging discrimination.

In Agreement: Yes No

3. Check whether there are any pending applications to other Federal agencies for assistance, and of Federal assistance being provided at the time of the application or requested report.

• No other applications for Federal assistance are pending

• Other applications for Federal assistance are pending

• Federal assistance is being provided at the time of the application/requested report

*If applications for assistance are pending, or Federal assistance is being provided, please provide a brief description, and forward NRC/SBCR all related documentation.

4. Check whether any civil rights compliance reviews have been conducted during the two-year period before the application, and forward information concerning the agency or organization performing the review; and any periodic statements regarding such reviews.

Check the correct block(s):

• No civil rights compliance reviews have been conducted

• One or more civil rights compliance reviews have been conducted

• No findings of a noncompliance with any relevant civil rights requirement

• One or more findings of a noncompliance with a relevant civil rights requirement

*If civil rights compliance reviews have been conducted, or there has been a finding of a noncompliance with a civil rights requirement, please provide a brief description, and forward NRC/SBCR all related documentation.

5. Please sign and date below indicating your agreement to compile and maintain the records required, pursuant to NRC=s guidelines, and Civil Rights directives.

Signature Date