Information Collection

NRC Form 4 (3150-0005 Agreement State Licensees RK Burden)

IC 181279 under ICR 200805-3150-002 · OMB 3150-0203.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0203 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NRC Form 4 NRC Form 4 (3150-0005 Agreement State Licensees RK Burden)	Form and Instruction
NRC Form 4 Cumulative Occupational Dose History nrc4.pdf	Form and Instruction

IC Title:

NRC Form 4 (3150-0005 Agreement State Licensees RK Burden)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 20

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 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: 24

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	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.