NRC Form 4, Cumulative Occupational Dose History

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0005 can be found here:

Documents and Forms

Document Name Document Type
Form NRC Form 4 NRC Form 4, Cumulative Occupational Dose History Form and Instruction
NRC Form 4 Cumulative Occupational Dose History NRC Form 4.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NRC Form 4, Cumulative Occupational Dose History	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 4	Cumulative Occupational Dose History	NRC Form 4.pdf		Yes	Yes	Fillable Printable

Line of Business: Energy

Subfunction: Energy Resource Management

Privacy Act System of Records
Title: NRC-27, Radiation Exposure Information and Reports System (REIRS) Files	FR Citation: 77 FR 67203

Number of Respondents: 4,146	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,146	0	298	3,848
Annual IC Time Burden (Hours)	31,234	345	12,479	18,410
Annual IC Cost Burden (Dollars)	2,668	0	2,668	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.