Form NRC Form 237 NRC Form 237 Request for Access Authorization

NRC FORM 237

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-XXXX

(M-YYYY)
NRCMD 12.3

REQUEST FOR ACCESS AUTHORIZATION

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory information collection request: 16
minutes. This submittal is used by NRC to determine the validity of the requirements for access.
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-XXXX), 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.

1. DATE

INSTRUCTIONS: Submit original only. Detailed instructions on the reverse.
2. TO:

3. FROM: (Name and abbreviated organization)

CHIEF
PERSONNEL SECURITY BRANCH
DIVISION OF FACILITIES AND SECURITY
OFFICE OF ADMINISTRATION
U.S. NUCLEAR REGULATORY COMMISSION
WASHINGTON, DC 20555-0001

4. SIGNATURE

5. REQUEST THE BELOW NAMED APPLICANT(S), U.S. CITIZEN(S), BE PROCESSED
FOR AN NRC ACCESS AUTHORIZATION AS INDICATED:
6. NAME OF APPLICANT (Last, First, Middle)

or

"Q"

"U"

"L"

"R"

SEE ATTACHED LIST OF APPLICANTS

"SGI"

7. SOCIAL SECURITY NUMBER

8. REMARKS - Include current or former security clearances and granting agency.

9. NRC SPONSORING OFFICE OR DIVISION (See instructions)

11. ENCLOSURES
FAIR CREDIT REPORTING ACT OF 1970, AS AMENDED (RELEASE)

10. CONTRACT NUMBER OR NAME OF LICENSEE

12. APPROVAL BY NRC SPONSORING OFFICIAL
A. NAME AND TITLE (Division Director or higher)

PAYMENT (CHECK) IF APPLICABLE
FD 258, FINGERPRINT CARDS (Two copies)
B. SIGNATURE
NRC FORM 176(A), SECURITY ACKNOWLEDGMENT
(For "Q" and "L" Requests)
NRC FORM 176(B), SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION
ACKNOWLEDGMENT (For "U" and "R" Requests).
OTHER (Specify)
NRC FORM 237 (M-YYYY)

C. DATE

INSTRUCTIONS
A. PURPOSE OF FORM:
This form is to be used for requesting NRC access authorizations for employees of NRC contractors,
subcontractors, licensee employees, employees of other government agencies, or other individuals
who are not applicants for employment with NRC. Use of this form is required by NRC Management
Directive 12.3 for NRC contractors and 10 CFR Parts 11 and 25 for NRC licensees.
B. MULTIPLE REQUESTS:
A single NRC Form 237 may be used to request access authorizations for several individuals who all
require the same type of access authorization (e.g., all "Qs" or all "Rs"). The individuals and their
social security numbers may be listed in the remarks section or on a roster appended to the NRC
Form 237.
C. WHO PREPARES THE FORM:
The agency or firm employing the individual(s) normally prepares this form (except in the case of a
subcontractor, in which case the prime contractor will prepare this form). The NRC sponsoring office
or division may prepare this form in the interest of expediency.
D. APPROVALS REQUIRED:
Item 4 must be signed by the agency or firm security officer (or other authorized official). If this
request is in connection with an NRC contract, or anticipated contract (e.g. basic ordering agreement),
or for access authorization for licensee personnel or licensee contractor or agents, Items 9 and 10
must be completed and the request must be approved in Item 12.
E. SUBMITTING THE REQUEST:
All requests may be submitted to the address in Item 2; however, when approval in Item 12 is
required, it will avoid delay in processing if this request is submitted through the approving NRC
official. Security forms completed by the applicant(s) are to be firmly attached to this form. (For
certification of an existing security clearance or federal access authorization, NRC licensee related
activities should consult 10 CFR Parts 11 or 25, as appropriate, for requested forms and related
procedures and fees.)
F. PRIOR INVESTIGATIONS AND SECURITY CLEARANCES:
To assist in the processing of this request, please list in Item 8 or attached roster:
1. Any prior investigations on the applicant(s). Give date, type (i.e., background investigation or
national agency checks), and investigating agency; and
2. Any current or prior security clearances (i.e., access authorizations) held by the applicant(s) with
NRC or any other agency. Give dates held, level (i.e., Top Secret, Secret, Confidential, "Q," "L,"
"U," or "R"), and agency granting clearance.