Form NRC Form 445 NRC Form 445 Request for Approval of Official Foreign Travel

PRIVACY ACT STATEMENT
NRC FORM 445
REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570),
the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory
Commission (NRC) on NRC Form 445. This information is maintained in a system of records designated as
NRC-20 and described at 77 Federal Register 67218 (November 8, 2012), or the most recent Federal Register
publication of the NRC's “Republication of Systems of Records Notices” located in the NRC's Agencywide
Documents Access and Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter 61; 41
CFR 102-118; Executive Order (E.O.) 9397, as amended by E.O. 13478.
2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.
3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the
NRC may disclose information from this system of records to the U.S. Treasury for payment; the
Department of State or an embassy for passports or visas; the General Services Administration and the
Office of Management and Budget for required periodic reporting; the charge card issuing bank; the
Department of Interior, National Business Center, for collecting severe travel card delinquencies by
employee salary offset; and to a consumer reporting agency to obtain credit reports. The information may
also be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information
indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to
an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC
decision about you or to the extent relevant and necessary for that agency's decision about you; in the
course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting
evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts,
consultants, and others under contract with the NRC, on a need-to-know basis; and to appropriate persons
and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach
of data from this system of records.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT
PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided
approval for foreign travel may be denied.
5. SYSTEM MANAGER AND ADDRESS: Chief, Financial Operations Branch, Division of the Controller,
Office of the Chief Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.
For passport and visa records: Chief, International Operations Branch, Office of International Programs,
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 445
(MM-YYYY)
NRC MD 14.1

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0193

REQUEST FOR APPROVAL OF OFFICIAL
FOREIGN TRAVEL
MUST BE COMPLETED 30 DAYS PRIOR TO TRAVEL
CONTACT IN OFFICE OR REGION

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this voluntary collection request: 2 hours. NRC uses
this form to authorize foreign travel for non-Federal personnel in the course of conducting business
for the NRC. 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, (3150-0193), 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 .
PROGRAM OFFICE

MAIL STOP

A. REVIEW AND APPROVAL
SIGNATURE -- OFFICE DIRECTOR/REGIONAL ADMINISTRATOR

DATE

SIGNATURE -- DEPUTY DIRECTOR, OIP (if required)

DATE

SIGNATURE -- CHAIRMAN (if required)

DATE

B. TRAVELER INFORMATION (To be completed by traveler)
1. NAME OF TRAVELER (Print or Type -- Last, first and middle initial)

2. IS YOUR PASSPORT VALID FOR THE NEXT 6 MONTHS?

YES

4. DATE OF DEPARTURE FROM THE U.S. 5. DATE OF RETURN TO THE U.S.

NO

YES

3. DOES YOUR TRIP REQUIRE A VISA?

NO

6. POSITION TITLE (Include profession)

7. COMPLETE NAME (No abbreviations) AND COMPLETE ADDRESS OF EMPLOYER (Include Number, Street, City, State and ZIP Code)

I acknowledge my responsibility as an international traveler to obtain a briefing on the most recent status of the threat environment
for my destination before leaving on travel. I will take all recommended precautions and, as appropriate, make use of Governmentissued IT devices for my official communications while on official travel. I understand that I may obtain travel alerts and/or travel
warnings by visiting the following website: http://travel.state.gov/content/passports/english/alertswarnings.html.
9. DATE

8. SIGNATURE -- TRAVELER'S CERTIFICATION

10. PURPOSE OF TRAVEL

Note: It is strongly recommended that you contact the NRC Health Center (301) 415-8400 in a timely fashion to consult on possible medical issues
and precautions, including the possibility of getting recommended inoculations or other medications and educational materials. This is particularly
important when travel is contemplated to developing nations, or away from the mainstream locations. Once your appointment is made, your chart will
be reviewed by the doctor and you will be notified if a visit is necessary.
11. LIST OF PERSONS WITH WHOM TRAVEL HAS BEEN COORDINATED (within NRC and in other U.S. Government agencies)(Name and agency)
Agency

Name

NRC FORM 445 (09-2012)

ORIG TO
OCFO/TSS

COPY TO
DFS/INFOSEC

COPY TO
OIP

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 445
(MM-YYYY)
NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (continued)

12. LIST OTHER NRC TRAVELERS AND CONTRACTORS GOING TO SAME FOREIGN MEETING OR DESTINATION
Name

Agency

13a. JOB CODE

13. SOURCE OF FUNDING

14. PROPOSED ITINERARY If this information is CLASSIFIED, be sure to CLASSIFY THIS FORM appropriately.
(Account for all time from beginning through ending dates of travel)

DATES

NRC FORM 445 (MM-YYYY)

LOCATION
(Installation, City, Country)

INDIVIDUALS TO
BE CONTACTED

SUBJECT OF
DISCUSSION

"X" IF
CLASSIFIED

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