Form NRC Form 237 NRC Form 237 Request for Access Authorization

PRIVACY ACT STATEMENT
NRC FORM 237
REQUEST FOR ACCESS AUTHORIZATION
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 237. 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 NRCs 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): For requesting NRC access authorizations for employees of NRC
contractors, subcontractors, licensees and other government agencies, or other individuals who are
not employees of or applicants for employment with the NRC.

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/certify clearance or access authorization; to determine eligibility for access to NRC
buildings or access to Federal automated information systems or data; to maintain the NRC
personnel security program; and to provide licensees criminal history information needed for their
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 and in the course of an administrative or
judicial proceeding. In addition, this information may be transferred 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. Information may also be
disclosed, 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, or to NRC-paid experts, consultants, and others under contract with the NRC, on a
need-to-know basis.

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 237
(10-2013)
NRCMD 12.3

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0050

REQUEST FOR
ACCESS AUTHORIZATION

EXPIRES: 10/31/2016

Estimated burden per response to comply with this mandatory information collection request: 16
minutes. This submittal is used by NRC to determine the validity of the requirements for access.
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, (3150-0050), 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.

1. DATE

INSTRUCTIONS: Submit original only. Detailed instructions are on the next page.
2. TO:

CHIEF
PERSONNEL SECURITY BRANCH
DIVISION OF FACILITIES AND SECURITY
OFFICE OF ADMINISTRATION
U.S. NUCLEAR REGULATORY COMMISSION
WASHINGTON, DC 20555-0001

3. FROM: (Name and abbreviated organization)

4. SIGNATURE

5. REQUEST THE BELOW NAMED APPLICANT(S), U.S. CITIZEN(S), BE PROCESSED
FOR AN NRC ACCESS AUTHORIZATION AS INDICATED:
6. NAME OF APPLICANT (Last, First, Middle) or

"Q"

"U"

"L"

"R"

SEE ATTACHED LIST OF APPLICANTS

"SGI"

7. SOCIAL SECURITY NUMBER

8. REMARKS -Include current or former security clearances and granting agency.

9. NRC SPONSORING OFFICE OR DIVISION (See instructions)

10. CONTRACT NUMBER OR NAME OF LICENSEE

11. ENCLOSURES

12. APPROVAL BY NRC SPONSORING OFFICIAL

FAIR CREDIT REPORTING ACT OF 1970, AS AMENDED (RELEASE)

A. NAME AND TITLE (Division Director or higher)

PAYMENT (CHECK) IF APPLICABLE
FD 258, FINGERPRINT CARDS (Two copies)
NRC FORM 176(A), SECURITY ACKNOWLEDGMENT
(For "Q" and "L" Requests)

B. SIGNATURE

NRC FORM 176(B), SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION
ACKNOWLEDGMENT (For "U" and "R" Requests).
OTHER (Specify)

NRC FORM 237 (10-2013)

C. DATE

INSTRUCTIONS
A. PURPOSE OF FORM:
This form is to be used for requesting NRC access authorizations for employees of NRC contractors,
subcontractors, licensee employees, employees of other government agencies, or other individuals
who are not applicants for employment with NRC. Use of this form is required by NRC Management
Directive 12.3 for NRC contractors and 10 CFR Parts 11 and 25 for NRC licensees.
B. MULTIPLE REQUESTS:
A single NRC Form 237 may be used to request access authorizations for several individuals who all
require the same type of access authorization (e.g., all "Qs" or all "Rs"). The individuals and their
social security numbers may be listed in the remarks section or on a roster appended to the NRC
Form 237.
C. WHO PREPARES THE FORM:
The agency or firm employing the individual(s) normally prepares this form (except in the case of a
subcontractor, in which case the prime contractor will prepare this form). The NRC sponsoring office
or division may prepare this form in the interest of expediency.
D. APPROVALS REQUIRED:
Item 4 must be signed by the agency or firm security officer (or other authorized official). If this
request is in connection with an NRC contract, or anticipated contract (e.g. basic ordering agreement),
or for access authorization for licensee personnel or licensee contractor or agents, Items 9 and 10
must be completed and the request must be approved in Item 12.
E. SUBMITTING THE REQUEST:
All requests may be submitted to the address in Item 2; however, when approval in Item 12 is
required, it will avoid delay in processing if this request is submitted through the approving NRC
official. Security forms completed by the applicant(s) are to be firmly attached to this form. (For
certification of an existing security clearance or federal access authorization, NRC licensee related
activities should consult 10 CFR Parts 11 or 25, as appropriate, for requested forms and related
procedures and fees.)
F. PRIOR INVESTIGATIONS AND SECURITY CLEARANCES:
To assist in the processing of this request, please list in Item 8 or attached roster:
1. Any prior investigations on the applicant(s). Give date, type (i.e., background investigation or
national agency checks), and investigating agency; and
2. Any current or prior security clearances (i.e., access authorizations) held by the applicant(s) with
NRC or any other agency. Give dates held, level (i.e., Top Secret, Secret, Confidential, "Q," "L,"
"U," or "R"), and agency granting clearance.