Form NRC Form 781 NRC Form 781 SBCR Compliance Review Part A

NRC FORM 781
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

SBCR COMPLIANCE REVIEW
PART A

APPROVED BY OMB: NOs. 3150-0053, 3150-0209

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 Information Services Branch (T-6 A10), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by 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 IV Arlington, Texas or surrounding areas

Region I King of Prussia, Pennsylvania or surrounding areas

Other (Specify)

Region II Atlanta, Georgia or surrounding areas
Region III Lisle, Illinois or surrounding areas
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.

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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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U.S. NUCLEAR REGULATORY COMMISSION

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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

Yes

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

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.
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

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 review have been conducted
No 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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SBCR COMPLIANCE REVIEW PART C
ADDITIONAL TITLE IX INFORMATION
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

Yes
No
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).
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.
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
No
Yes
No
Yes
No

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 any investigations of complaints or
noncompliance with Title IX regulations.
Has and will continue to provide notification to all of the recipient's students and employees of the name, office address, and
telephone number of the employee or employees designated to coordinate the recipient's Title IX efforts.
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 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
No

Yes
No
Yes
No
Yes
No
Yes
No

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 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).
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 connection with any recruitment of students
or employees.
Ensures that the notification is widely disseminated and easily understood.
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 Title IX regulations.
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 requires that the representatives
adhere to the policies.

NRC FORM 781 (MM-YYYY)

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