Form NRC-445 Foreign Travel

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the
following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission
(NRC) on NRC Form 445. This information is maintained in a system of records designated as NRC-20 and
described at 71 Federal Register 59628 (October 10, 2006), or the most recent Federal Register publication of the
NRC's "Republication of Systems of Records Notices" located in the NRC's Agencywide Documents Access and
Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. 5701; 31 U.S.C. 716, 1104, 1108, 3511, 3512, 3701, 3711, 3717, 3718, 3726; Federal
Travel Regulations, 41 CFR parts 301-304; Federal Property Management Regulations, 41 CFR part 101-41;
Executive Order 9397; Section 639 of the Consolidated Appropriations Act, 2005 (P.L. 108-447).
2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.
3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may
disclose information from this system of records to the U.S. Treasury for payment; the Department of State or an
embassy for passports or visas; the General Services Administration and the Office of Management and Budget
for required periodic reporting; the charge card issuing bank; the Department of Interior, National Business
Center, for collecting severe travel card delinquencies by employee salary offset; and to a consumer reporting
agency to obtain credit reports. The information may also be disclosed to an appropriate Federal, State, local or
Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an
administrative or judicial proceeding; to an appropriate Federal, State, local and Foreign agency to the extent
relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's
decision about you; in the course of discovery under a protective order issued by a court of competent
jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your
request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis;
and to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected
or confirmed breach of data from this system of records.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT
PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided
approval for foreign travel may be denied.
5. SYSTEM MANAGER AND ADDRESS: Chief, Travel Services Team, Division of Financial Services, Office of the
Chief Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 445

U.S. NUCLEAR REGULATORY COMMISSION

(12-2007)
NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL
FOREIGN TRAVEL

APPROVED BY OMB: NO. 3150-0193

EXPIRES: 08/31/2008

Estimated burden per response to comply with this voluntary collection request: 1
hour. NRC uses this form to authorize foreign travel for non-Federal personnel in the
course of conducting business for the NRC. Send comments regarding burden
estimate to the Records and FOIA/Privacy Services Branch (T-5 F53), 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, (3150-0193), 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.

MUST BE COMPLETED 30 DAYS PRIOR TO TRAVEL
PROGRAM OFFICE

CONTACT IN OFFICE OR REGION

MAIL STOP

A. REVIEW AND APPROVAL
SIGNATURE -- OFFICE DIRECTOR/REGIONAL ADMINISTRATOR

DATE

SIGNATURE -- DIRECTOR, OIP (if required)

DATE

SIGNATURE -- CHAIRMAN (if required)

DATE

B. TRAVELER INFORMATION (To be completed by traveler)
1. NAME OF TRAVELER (Print or Type -- Last, first and middle initial)

3. DATE OF DEPARTURE

2. IS YOUR PASSPORT CURRENT?

YES

NO

4. POSITION TITLE (Include profession)

5. EMPLOYER

6. EMPLOYER ADDRESS

7. EMPLOYER CITY (Include ZIP Code)

8. SIGNATURE -- TRAVELER

9. DATE

10. PURPOSE OF TRAVEL

11. LIST OF PERSONS WITH WHOM TRAVEL HAS BEEN COORDINATED
(within N RC and in other U.S. Government agencies)

12. LIST OTHER NRC TRAVELERS AND CONTRACTORS GOING
TO SAME FOREIGN MEETING OR DESTINATION

13. SOURCE OF FUNDING

NRC FORM 445 (12-2007)

ORIG TO
OCFO/TSS

COPY TO
DFS/INFOSEC

COPY TO
OIP

PRINTED ON RECYCLED PAPER

14. PROPOSED ITINERARY If this information is CLASSIFIED, be sure to CLASSIFY THIS FORM appropriately.
(Account for all time from beginning through ending dates of travel)
DATES

LOCATION
(Installation, City, Country)

INDIVIDUALS TO
BE CONTACTED

SUBJECT OF
DISCUSSION

"X" IF
CLASSIFIED

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the following
statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form
445. This information is maintained in a system of records designated as NRC-20 and described at 71 Federal Register 59628
(October 10, 2006), or the most recent Federal Register publication of the NRC's "Republication of Systems of Records
Notices" located in the NRC's Agencywide Documents Access and Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. 5701; 31 U.S.C. 716, 1104, 1108, 3511, 3512, 3701, 3711, 3717, 3718, 3726; Federal Travel
Regulations, 41 CFR parts 301-304; Federal Property Management Regulations, 41 CFR part 101-41; Executive Order 9397;
Section 639 of the Consolidated Appropriations Act, 2005 (P.L. 108-447).
2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.
3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may disclose
information from this system of records to the U.S. Treasury for payment; the Department of State or an embassy for
passports or visas; the General Services Administration and the Office of Management and Budget for required periodic
reporting; the charge card issuing bank; the Department of Interior, National Business Center, for collecting severe travel card
delinquencies by employee salary offset; and to a consumer reporting agency to obtain credit reports. The information may
also be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or
potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and
Foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary
for that agency's decision about you; in the course of discovery under a protective order issued by a court of competent
jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to
NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; and to appropriate persons
and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this
system of records.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING
INFORMATION: Disclosure is voluntary, however, if the requested information is not provided approval for foreign travel may
be denied.
5. SYSTEM MANAGER AND ADDRESS: Chief, Travel Services Team, Division of Financial Services, Office of the Chief
Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.
NRC FORM 445 (12-2007)

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