Form DOE F 470.3 DOE F 470.3 Human Reliability Program (HRP) Certification

DOE F 470.3 (07/03)

Replaces DOE F 5631.35 All other editions obsolete.

OFFICIAL USE ONLY

OMB Control No. 1910-5122

U.S. DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM (HRP) CERTIFICATION
NAME:	INITIAL [ ] ANNUAL [ ]
POSITION: DRUG TESTING DATE: EMPLOYER: ALCOHOL TESTING DATE: ANNIVERSARY/DUE DATE: TRAINING COMPLETION DATE: COUNTERINTELLIGENCE EVALUATION APPROVAL DATE:
SECTION A - SUPERVISORY REVIEW I have reviewed all available information regarding this individual and have no reason to believe that this individual may represent a security or safety concern. (If you cannot make such an affirmation, then do not sign here and attach a signed explanation.) SUPERVISOR: DATE:
SECTION B - MEDICAL ASSESSMENT I have reviewed this individual’s medical files (including the examining physician=s medical report and psychological evaluation) and I have no reason to believe that this individual may represent a security or safety concern. (If you cannot make such an affirmation, then do not sign here and attach a signed explanation.) SITE OCCUPATIONAL MEDICAL DIRECTOR: DATE:
SECTION C - MANAGEMENT EVALUATION All relevant information concerning this individual (including the results of drug and alcohol testing) has been reviewed, and I have no reason to believe that this individual may represent a security or safety concern; therefore, I recommend that this individual be reviewed for HRP certification. (If you cannot make such an affirmation, then do not sign here and attach a signed explanation.) MANAGEMENT OFFICIAL: DATE:

OFFICIAL USE ONLY

May be exempt from public release under the Freedom

of Information Act (5 U.S.C. 552) Exemption (b)(6), Personal Privacy. Department of Energy review required before public release Name/Org: Date:

OFFICIAL USE ONLY

(when shaded area filled in)

U.S. DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM (HRP) CERTIFICATION

SECTION D - DOE PERSONNEL SECURITY REVIEW

[ ] Recommend HRP certification be granted/continued.

[ ] Recommend remanding for further clarifying information. [ ] Process under 10 CFR 710.

PERSONNEL SECURITY SPECIALIST: DATE:

SECTION E - HRP CERTIFICATION DETERMINATION

[ ] HRP certification granted/continued.

[ ] HRP certification temporarily removed. [ ] HRP certification reinstated.

[ ] HRP certification revoked.

HRP CERTIFYING OFFICIAL: DATE:

OBM Disclosure Statement

Public reporting burden for this collection of information is estimated to average ten minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden, to Office of Security, HS-50, GTN, Paperwork Reduction Project (1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585- 1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-5122), Washington, DC 20503.

OFFICIAL USE ONLY

(when shaded area filled in)

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