DOE F 470.6 Refusal of Consent

DOE F 470.6 (07/03)
Replaces DOE F 5631.38
All other editions obsolete.

OMB Control No. 1910-5122

U.S. Department of Energy
OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average six 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 Business and Information Management, IM-10, 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.

REFUSAL OF CONSENT
The requirements of the Human Reliability Program (HRP) have been explained, and I hereby decline to
participate in the program. I acknowledge that this decision will result in my reassignment to non-HRP
duties, if available, and/or the termination of further processing of my certification for an HRP position.

____________________
Date

____________________________________________________
Employee (Signature)

____________________________________________________
HRP Management Official (Print Name and Signature)

Privacy Act Statement
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE)
to regulate the possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to
aid in the determination of an individual=s eligibility for an HRP certification. The information may also be provided to other agencies of the
United States government for investigations that involve protection of the national security, public health and safety, or the environment.
Submission of the information requested on this form is voluntary, but failure to provide the information may result in denial of an HRP
certification. If DOE uses the information for purposes other than those indicated in this statement, it will provide notice of those additional
purposes to persons who have submitted information on this form.