Information Collection

NRC Form 4, Cumulative Occupational Dose History

IC 33127 under ICR 201403-3150-001 · OMB 3150-0005.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.