Form NRC Form 445 NRC Form 445 Request for Approval of Official Foreign Travel

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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 75 Federal Register 57348 (September 20, 2010), or the most
recent Federal Register publication of the NRCs Republication of Systems of Records Notices located in
the NRCs Agencywide Documents Access and Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter
11; 41 CFR 102-118; Executive Order (E.O.) 9397, as amended by E.O. 13478.
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, Financial Operations Branch, Division of the Controller,
Office of the Chief Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC
20555-0001. For passport and visa records: Chief, International Operations Branch, Office of
International Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

GO TO PRIVACY ACT STATEMENT
NRC FORM 445
(M-YYYY)
NRC MD 14.1

EXPIRES: MM/DD/YYYY

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0193

MUST BE COMPLETED 30 DAYS PRIOR TO TRAVEL

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
Information 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 .

CONTACT IN OFFICE OR REGION

PROGRAM OFFICE

REQUEST FOR APPROVAL OF OFFICIAL
FOREIGN TRAVEL

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

3a. DATE OF RETURN

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 NRC and in other U.S. Government agencies)(Name and agency)
Name

NRC FORM 445 (M-YYYY)

Agency

ORIG TO
OCFO/TSS

COPY TO
DFS/INFOSEC

COPY TO
OIP

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

13. SOURCE OF FUNDING

Agency

13a. JOB CODE

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

NRC FORM 445 (M-YYYY

LOCATION
(Installation, City, Country)

INDIVIDUALS TO
BE CONTACTED

SUBJECT OF
DISCUSSION

"X" IF
CLASSIFIED

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