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⚠️ Notice: This information collection may be referencing outdated material.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 Form 4 NRC Form 4, Cumulative Occupational Exposure History Form and Instruction
NRC Form 4 Cumulative Occupational Dose History nrc4.pdf Form and Instruction

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:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 4	Cumulative Occupational Dose History	nrc4.pdf		No		Fillable Printable

Line of Business: Energy

Subfunction: Energy Resource Management

Privacy Act System of Records
Title: NRC-27	FR Citation: 69 FR 57601

Number of Respondents: 227	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	227	-19,797	20,024
Annual IC Time Burden (Hours)	43	-9,969	10,012
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.