Form NRC Form 277 NRC Form 277 Request for Visit

PRIVACY ACT STATEMENT
NRC Form 277
Request for Visit
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the
following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC)
on NRC Form 277. This information is maintained in a system of records designated as NRC-39 and described at 77
Federal Register 67231 (November 8, 2012), or the most recent Federal Register publication of the NRC's "Republication
of Systems of Records Notices" that is located in the NRC's Agencywide Documents Access and Management System
(ADAMS).
1. AUTHORITY: 42 U.S.C. 2011 et seq,; 42 U.S.C. 2165, 2201(i); 2201a, and 2284; 42 U.S.C. 5801 et seq.; Executive
Order (E.O.) 9397; as amended by E.O. 13478; E.O. 10450, as amended; E.O. 10865, as amended; E.O. 12958, as
amended by E.O. 13256; E.O. 13467; E.O. 13526; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130,
Revised; 5 CFR 731, 732, and authorities cited therein.
2. PRINCIPAL PURPOSE(S): To verify an individual's security clearance and level of access authorized during an
official visit.
3. ROUTINE USE(S): Information may be used on a need-to-know basis by NRC officials, Hearing Examiners,
Personnel Security Review Panel members, OPM, CIA and other Federal agencies to determine clearance or access
authorization eligibility; to determine eligibility for access to NRC buildings or access to Federal automated information
systems or data; to certify clearance or access authorization; to maintain the NRC personnel security program; and to
provide licensees criminal history information needed for unescorted access or access to safeguards information
determinations. Information may be disclosed in accordance with any of the Routine Uses listed in the Prefatory
Statement of General Routine Uses, including 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; or 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: : It is voluntary that you furnish the requested information, however, failure to provide the requested
information may result in the denial of entrance and/or access to the agency or facility and the information to which
access is requested. Failure to provide the Social Security number (SSN) may delay processing. The use of the SSN
is necessary to verify clearance information because of the large number of individuals who have identical names and
birth dates, and whose identities can only be distinguished by the SSN.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 277
(MM-YYYY)
NRC MD 12.3

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0051

REQUEST FOR VISIT
(Not to be used for temporary or permanent personnel assignments)

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory information collection request: 10 minutes.
This submittal is used to validate the level of access authorized during an official visit. 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 Infocollects.
[email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202,
(3150-0051), 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.

PART A
Date

To:

Personnel Security Branch, DFS/ADM
From (Requesting Office -- Branch Chief or Above)

Telephone Number

CERTIFY PURPOSE/NEED FOR VISIT REQUEST
SIGNATURE OF REQUESTING NRC OFFICIAL

Date

TITLE

NAME OF FACILITY(IES) TO BE VISITED

INCLUSIVE DATES
From

To

Purpose of visit:

Visit Point of contact:

Telephone

Facsimile

Security Point of contact:

Telephone

Facsimile

Program/Level of access requested:

Prior arrangements:

have not been made or

have been made as follows:

PART B
It is requested that the following person(s) be granted visit/access approval:
LAST NAME, FIRST NAME,
MIDDLE INITIAL

SOCIAL SECURITY
NUMBER
(9 digits)

U.S.
CITIZEN

DATE
OF
BIRTH

PO BIRTH/
COUNTRY

Date mm/dd/yyyy
TYPE OF
CLEARANCE

YES
YES
YES
YES
YES
Name/Title of NRC Security Official

Date

Signature

PART C
Remarks:

NRC FORM 277 (MM-YYYY)

Date mm/dd/yyyy
TYPE OF
INVESTIGATION