Form 781 Form 781 SBCR Complaince Review Park A, B, and C

NRC FORM 781
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NOs. 3150-0053, 3150-0209

SBCR COMPLIANCE REVIEW
PART A

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 1.5 hours (30 minutes
each for Parts A, B and C). This information is required by NRC to process payments to contractors.
Send comments regarding burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5
F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to
[email protected], and to the Desk Officer, Office of Information and Regulatory Affairs,
NEOB-10202, (3150-0053, 3150-0209), Office of Management and Budget, Washington, DC, 20503. If a
means used to impose an information collection does not display a currently valid OMB control number, the
NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

FOR SBCR USE ONLY

DATE COMPLIANCE REVIEW INQUIRY COMPLETED

APPLICANT NAME

APPLICATION FOR

PLEASE RESPOND TO ALL INQUIRIES & SUBMIT APPLICABLE PROGRAM INFORMATION & DOCUMENTS TO:
[email protected], OR FAX: (301) 415-5953
ATTENTION: OUTREACH AND COMPLIANCE COORDINATION PROGRAM
CONTACT NUMBER: (301) 415-7380
1. Program/Contract Services: Identify the manner in which services are or will be provided, and data/information
necessary for determining whether any persons are or will be denied such services on the basis of prohibited
discrimination.

2. Program Contract Population Served: Identify the geographic location(s) where program activities/services will be
provided.
Headquarters (Washington, DC Metropolitan areas)

Region III Lisle, Illinois or surrounding areas

Region I King of Prussia, Pennsylvania or surrounding
areas

Region IV Arlington, Texas or surrounding areas

Region II Atlanta, Georgia or surrounding areas

Other, Specify

3. Collection of EO Data: Recipients are required to track and maintain EO data regarding the population eligible to be
served and actual program participants (i.e., race, color, national origin, sex). How does/will the recipient program collect
EO data?

4. Limited English Proficiency: Provide information/data regarding covered employment, including use or planned use
of bilingual public-contact employees serving beneficiaries of the program where necessary to permit effective
participation by beneficiaries unable to speak or understand English.

NRC FORM 781 (MM-YYYY)

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NRC FORM 781

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U.S. NUCLEAR REGULATORY COMMISSION

SBCR COMPLIANCE REVIEW PART A (continued)
5. Facilities and/or Locations: Identify the location(s) of existing or proposed facilities connected with the program/
services, and related information adequate for determining whether the location has or will have the effect of unnecessarily
denying access to any persons on the basis of prohibited discrimination.

6. Organizational Membership: Identify the present or proposed membership, by race, color, sex, and national origin, in
any planning or advisory body which is an integral part of the program/service (e.g., 3 caucasian males, 2 african american
females, etc. Do NOT identify specific individuals in the group by name).

7. Changes in Location: If applicable, identify where relocation is involved, the requirements and steps used or
proposed to guard against unnecessary impact on persons in the protected classes identified in Question number 3.

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NRC FORM 781

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

SBCR COMPLIANCE REVIEW PART B
In Agreement:
1. Promptly notify NRC/SBCR upon its request of any lawsuit filed against the applicant or
recipient alleging discrimination on the basis of race, sex, color, national origin, disability,
religion, age, sexual orientation, or status as a parent.

Yes

No

2. Promptly notify NRC/SBCR upon any complaints filed against the recipient alleging
discrimination.

Yes

No

3. Submit compliance reports upon the agency's request to the Nuclear Regulatory
Commission Office of Small Business and Civil Rights (SBCR). Submit an
annual EO compliance report to SBCR no later than December 31 of each calendar year.

Yes

No

4. Provide comprehensive civil rights training for staff, and periodically retrain staff to
establish and update their knowledge of EO civil rights statutes and emerging issues.

Yes

No

5. Check whether there are any pending applications to other Federal Agencies for assistance, and of Federal
assistance being provided at the time of the application or requested report.
No other applications for Federal assistance are pending
Other applications for Federal Assistance are pending
Federal assistance is being provided at the time of the application/requested report
*If applications for assistance are pending, or Federal assistance is being provided, please
provide a brief description, and forward NRC/SBCR all related documentation.
6. Check whether any civil rights compliance reviews have been conducted during the two-year period before the
application, and forward information concerning the agency or organization performing the review; and any periodic
statements regarding such reviews.
No civil rights compliance review have been conducted
One or more civil rights compliance reviews have been conducted
No findings of a noncompliance with any relevant civil rights requirement
One or more findings of a noncompliance with a relevant civil rights requirement
*If civil rights compliance reviews have been conducted, or there has been a finding of a
noncompliance with a civil rights requirement, please provide a brief description, and
forward NRC/SBCR all related documentation.
7. Please type in your full name, title and date below indicating your agreement to compile and maintain the records
required, pursuant to NRC's guidelines, and Civil Rights directives.
Typed or Printed Name and Title

Date: (MM/DD/YYYY)

Signature

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 781

SBCR COMPLIANCE REVIEW PART C
ADDITIONAL TITLE IX INFORMATION

(MM-YYYY)

Please check the box that applies to your organization:
The recipient organization provides some type(s) of education programs or activities.
The recipient organization does not provide any education programs or activities.
This Section contains additional data collections imposed under Title IX of the Educational Amendments of 1972 and the
Nuclear Regulatory Commission Title IX implementing Regulations (NRC) set forth in Title 10 of the Code of Federal
Regulations, Part 5. Except as provided in §§5.205 through 5.235(a), of NRC's Title IX regulations, these requirements
apply to every recipient and to each education program or activity operated by a recipient that receives Federal financial
assistance.
Please check yes or no in the appropriate boxes to indicate whether your organization is in compliance with the following
Title IX requirements:
Required Title IX Assurances to Fulfill Requirements Under §5.135 and Title IX:
Yes
No

Provides assurance that all of the recipient's education programs or activities will be operated in compliance
with the nondiscrimination mandates of Title IX and NRC's implementing regulations (e.g., Admissions and
Recruitment. See §§5.300 through 5.310; Education Programs or Activities. See §§5.400 through 5.455;
and Employment in Education Programs or Activities. See §§5.500 through 5.550).

Yes
No

Provides assurance that the recipient will take whatever remedial action is necessary in accordance
with §5.110(a) to eliminate existing discrimination on the basis of sex or to eliminate the effects of past
discrimination whether occurring prior to or subsequent to the assurance given.

Yes
No

Provides assurance that the assurances in this section will be required of the applicant or recipient
sub-grantees, contractors, subcontractors, transferees, or successors in interest.

Please check the box that applies to your organization:
Designation of Title IX Coordinator, Notification to Students and Employees and Adoption of Grievance
Procedures to Fulfill Requirements Under §5.135 and Title IX:
Yes Has designated at least one responsible employee to coordinate Title IX compliance efforts and carry out
the recipient's responsibilities under Title IX and NRC's implementing regulations, including coordinating
No
any investigations of complaints or noncompliance with Title IX regulations.
Yes Has and will continue to provide notification to all of the recipient's students and employees of the name,
No office address, and telephone number of the employee or employees designated to coordinate the
recipient's Title IX efforts.
Yes Has adopted and published an internal grievance procedure to determine whether a particular act, policy,
or practice of the recipient complies with Title IX regulations; and that promptly and equitably resolves
No
complaints alleging discrimination on the basis of sex in education programs or activities.
Dissemination of Title IX Policy to Fulfill Requirements Under §5.140 and Title IX:
Yes Has taken specific steps to regularly and consistently notify the public - i.e., participants, employees,
applicants, etc. that the recipient does not discriminate on the basis of sex in the operation of its education
No programs and activities; Title IX and Title IX regulations also apply to employment in and admission to the
recipient's education programs and activities; and inquiries regarding Title IX and Title IX regulations may
be referred to the recipient's designated Title IX Coordinator, or Federal funding agency/official (i.e.,
Nuclear Regulatory Commission Office of Small Business and Civil Rights).
Yes Prominently publishes a statement of the Title IX policy described in this section in each announcement,
bulletin, catalog, or application form that the recipient makes available to the public or that is used in
No
connection with any recruitment of students or employees.
Yes
No

Ensures that the notification is widely disseminated and easily understood.

Yes Ensures that the recipient does not use or distribute a publication that suggests by its text or illustration that
it treats applicants, students or employees differently on the basis of sex-except as permitted under the
No
Title IX regulations.
Yes Distributes the recipient's Title IX policies without discrimination on the basis of sex, informs each of its
admission and employment recruitment representatives of the Title IX nondiscrimination policies, and
No
requires that the representatives adhere to the policies.
NRC FORM 781 (MM-YYYY)

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