NRC Form 4, Cumulative Occupational Dose History

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NRC Form 4 NRC Form 4, Cumulative Occupational Dose History	Form and Instruction	Modified	Available
Final NRC Form 4 SS.doc	Supporting Statement A	Uploaded 2014-03-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33127	NRC Form 4, Cumulative Occupational Dose History	Form and Instruction	Modified

ICR Details

OMB Control No: 3150-0005	ICR Reference No: 201403-3150-003
Status: Historical Active	Previous ICR Reference No: 201006-3150-005
Agency/Subagency: NRC	Agency Tracking No:
Title: NRC Form 4, Cumulative Occupational Dose History
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/11/2014
	Date Received in OIRA: 03/27/2014
Terms of Clearance: The agency is reminded to consult on the information collection prior to submission for review per 5 CFR 1320.8(d)(1).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	227,846	0	3,848
Time Burden (Hours)	31,234	0	18,410
Cost Burden (Dollars)	0	0	0

---

Abstract: The NRC Form 4 is used to record the summary of an occupational worker's cumulative occupational radiation dose, including prior occupational exposure and the current year's occupational radiation exposure. The NRC Form 4 is used by licensees, and inspected by the NRC, to ensure that occupational radiation doses do not exceed the regulatory limits specified in 10 CFR 20.1501.

---

Authorizing Statute(s): PL: Pub.L. 83 - 703 1-311 Name of Law: Atomic Energy Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 66076	11/04/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 13682	03/11/2014
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
NRC Form 4, Cumulative Occupational Dose History	NRC Form 4	Cumulative Occupational Dose History

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	227,846	3,848	0	0	223,998	0
Annual Time Burden (Hours)	31,234	18,410	0	345	12,479	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The estimated burden has increased by 12,824 hours from the previous burden of 18,410 hours to 31,234 hours. This increase has three primary reasons: 1) the increase in the number of transient workers, 2) the increase in the burden estimate by 5 minutes based on the inclusion of the new EDEX field on the form, and 3) the inclusion of 3rd party disclosure burden for the NRC Form 4. In addition to the increase in the number of transient workers, licensees provide an NRC Form 4 (or equivalent) to their employees even if the employee has not participated in a planned special exposure (2007 final rule). Licensees provide an NRC Form 4 (or equivalent) to employees pursuant to 10 CFR 19.13. Due to an increase in the number of transient workers, the number of hours associated with NRC Form 4 is anticipated to be higher in the current renewal cycle than in previous cycles: • In the previous clearance (prior to the 2007 final rule), based on REIRS data, NRC estimated that licensees would maintain NRC Form 4, or its equivalent, records for 28,780 transient workers. A review of recent REIRS data shows that as of June 2013, licensees maintained NRC Form 4, or its equivalent, records for an average of 33,518 transient workers annually. In addition to licensees in the REIRS system, in the current clearance, NRC has included the transient workers employed by 3,946 additional materials licensees. These licensees are not subject to 20.2206(a); therefore, their data is not included in the REIRS system. These licensees were not included in the estimates in the previous clearance; however, NRC inspection findings indicate that these licensees are voluntarily maintaining NRC Form 4 for their workers. The NRC estimates that these licensees are maintaining Form 4 for an additional 8,760 transient workers. The addition of these 3,946 sites to the estimates has greatly increased the estimated number of respondents. The second reason for the increase in the estimated burden is an increase in the estimated time to complete NRC Form 4, from 30 minutes to 35 minutes. Prior to the 2007 final rule, the estimate to complete NRC Form 4 was 30 minutes. Because it takes less time to complete NRC Form 4 for a planned special exposure, the burden was reduced to 15 minutes. However, because licensees primarily use the NRC Form 4 to record an employee's cumulative exposure, the burden estimate was changed to 30 minutes. The burden estimate has further changed from 30 minutes to 35 minutes to include the new "EDEX" field. The addition of this field is needed so that licensees can comply with the definition of the total effective dose equivalent (TEDE) in 10 CFR 20.1003. The change in TEDE definition was part of the December 2007 final rule on 10 CFR Parts 19, 20, and 50 (72 FR 68043). This change of 5 minutes accounts for 345 hours of burden, and has been accounted for as a program change due to agency discretion. Finally, in addition to taking 35 minutes to complete the NRC Form 4, in this renewal, an additional 2 minutes per worker has been added to account for the time spent by licensees to provide a copy of the NRC Form 4 to their workers. The NRC staff estimates that licensees use an additional 2 minutes to print the form (or its equivalent) and provide it to their employees. This is not a change in requirements, but a change in how the NRC is accounting for the 3rd-party disclosure aspect of the collection. This resulted in an additional 6,711 hours for this clearance. It should be noted that the NRC does not anticipate any planned special exposures during the next three years; therefore, all licensees that use the NRC Form 4 for the next three years will be on a voluntary basis.

---

Annual Cost to Federal Government: $138,230

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/27/2014

---