DOE F 470.4 HRP Acknowledgment and Agreement

DOE F 470.4
(05/16/Administrative Update 05/2016)
All other editions obsolete.

OMB Control No. 1910-5122

U.S. Department of Energy
OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average two minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for
reducing this burden, to the Office of Environment, Health, Safety and Security, AU-1.2, FSTL. GTN, Paperwork Reduction Project
(1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585-1290; and to the Office of Management
and Budget (OMB), Paperwork Reduction Project (1910-5122), Washington, DC 20503.

ACKNOWLEDGMENT AND AGREEMENT
TO PARTICIPATE IN THE HUMAN RELIABILITY PROGRAM (HRP)
I,
HRP position.

, acknowledge that I am seeking to occupy or retain an

I recognize that the Department of Energy (DOE) has the highest of national security, safety, and public
health interests in assuring that individuals occupying HRP positions meet the highest standards of human
reliability.
I acknowledge that I have been advised of the requirements for occupying, or continuing to occupy, an
HRP position. I have also been advised of my responsibilities under the program. The HRP components,
including supervisory review, medical assessment, psychological examination, testing for the use of
illegal drugs, random alcohol testing, management recommendation, and the DOE security review and
clearance determination, have been fully explained to me.
I hereby consent and agree to submit to all components under the HRP and further consent and agree to
cooperate fully with
(contractor) and/or the DOE in the
assessment of my eligibility or certification to an HRP position.

Date

Employee (Signature)

HRP Management Official (Print Name and Signature)

Privacy Act Statement
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE)
to regulate the possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to
aid in the determination of an individual’s eligibility for an HRP certification. The information may also be provided to other agencies of the
United States government for investigations that involve protection of the national security, public health and safety, or the environment.
Submission of the information requested on this form is voluntary, but failure to provide the information may result in denial of an HRP
certification. If DOE uses the information for purposes other than those indicated in this statement, it will provide notice of those additional
purposes to persons who have submitted information on this form.