NRC Form 176- Final Supporting Statement

FINAL SUPPORTING STATEMENT FOR
NRC FORM 176
“SECURITY ACKNOWLEDGMENT AND TERMINATION STATEMENT”
(3150-XXXX)
NEW
Description of the Information Collection
The reporting requirements associated with the U.S. Nuclear Regulatory Commission (NRC) Form 176,
"Security Acknowledgement and Termination Statement," affect the NRC employees, licensees, and
contractors who have been granted an NRC access authorization (security clearance). When an applicant
requires an NRC access authorization he/she shall sign the NRC Form 176 prior to access to Restricted
Data, Controlled Unclassified Information, and/or Special Nuclear Materials. When the NRC access
authorization is no longer required, the employee or contractor acknowledges and accepts his/her continuing
security responsibilities, as stated on the NRC Form 176, by signing the form.
The NRC Form 176 requires a minimum amount of personal information (e.g., name, date of termination, last
four digits of social security number, and name the person providing the briefing). The form is countersigned
by an Office of Administration, Division of Facilities and Security (DFS) employee, or representative of the
licensee or contractor who administered the completion of the form by the employee, licensee, or contractor.
There is no recordkeeping requirement for the NRC employee, licensee, or contractor since the completed
NRC Form 176 is to be forwarded to NRC headquarters, DFS for retention in the individual's Personnel
Security File (PSF). The established retention period of the PSF is destroyed upon notification of death or 5
years after termination of the last access authorization held.
The use of this form affords some assurance that access to classified information, Restricted Data (as defined
by Section 11.y. of the Atomic Energy Act of 1954 (42 U.S.C. § 2014)), Controlled Unclassified Information
(as defined by 32 C.F.R. Part 2002 Controlled Unclassified Information), and special nuclear material, as well
as the knowledge gained by the respondent will be properly protected, and therefore, benefits the NRC
security program and public at large.
A.

JUSTIFICATION
1. Need for and Practical Utility of the Information Collection
Section 4.3 of Executive Order (E.O.) 12958 requires agencies to establish controls over the
distribution of classified information to assure that it is distributed only to organizations or
individuals eligible for access who also have a need-to-know the information. When an
applicant requires an NRC access authorization he/she shall sign the NRC Form 176 prior to
access to Restricted Data, Controlled Unclassified Information, and/or Special Nuclear
Materials. When an individual with access to classified information, Restricted Data,
Controlled Unclassified Information and/or special nuclear material is no longer employed in a
position requiring access to such information/material, the NRC will terminate the individual’s
access authorization in accordance with 10 CFR 25.33 (applicable to licensees) or in
accordance with 10 CFR Part 10 and NRC Management Directive (MD) 12.3, “NRC Personnel
Security Program” (applicable to NRC employees and contractors). The NRC Form 176 is an
integral part of reminding individuals of their continuing responsibilities after termination of
service.
2.

Agency Use of Information

As stated in MD 12.3 (for employees and contractors) and in 10 CFR 25.33 (for licensees),
the completed NRC Form 176 is to be forwarded by the employee/licensee/contractor to NRC
headquarters for use by DFS in connection with the security acknowledgment and termination
of the respondent’s employment with the NRC. In addition to providing assurance of NRC
compliance with E.O. 12958, the NRC Form 176 is the vehicle used by DFS to apprise the
individual of his/her continuing responsibilities for protecting classified information, Restricted
Data, and Controlled Unclassified Information that he/she had access to, in the course of
performing official duties. The individual’s signature on this form indicates their
acknowledgment/acceptance of these continuing responsibilities.
Failure to use the NRC Form 176 by the licensee/contractor may result in: (1) failure to
properly investigate an applicant for the appropriate access authorization; (2) failure to
terminate the NRC access authorization when circumstances dictate and, therefore,
unnecessary continued access to classified information, Restricted Data, and/or Controlled
Unclassified Information; and (3) the individual not being apprised of, or officially
acknowledging (by signature) his/her continuing responsibilities for protecting classified
information, Restricted Data, and/or Controlled Unclassified Information.
3.

Reduction of Burden Through Information Technology
The NRC has issued Guidance for Electronic Submissions to the NRC which provides
direction for the electronic transmission and submittal of documents to the NRC. Electronic
transmission and submittal of documents can be accomplished via the following avenues: the
Electronic Information Exchange (EIE) process, which is available from the NRC's “Electronic
Submittals” Web page, by Optical Storage Media (OSM) (e.g. CD-ROM, DVD), by facsimile or
by e-mail. It is estimated that approximately less than 5% of the responses are filed
electronically.

4.

Effort to Identify Duplication and Use Similar Information
No sources of similar information are available. There is no duplication of requirements.

5.

Effort to Reduce Small Business Burden
The burden associated with this form is minimal. There is no significant burden on a
contractor that is a small business enterprise or entity.

6.

Consequences to Federal Program or Policy Activities if the Collection is not Conducted
or is Conducted Less Frequently
The frequency of information collection is limited to circumstances when the respondent’s
NRC service is to be investigated for access authorization and approved access authorization
needs to be terminated. In most cases, an individual will need to sign the NRC Form 176
twice. If the information is not collected, the assurance that only appropriately cleared
individuals have access to classified information is reduced. Furthermore, it is likely that
individuals will be unaware of their continued responsibility to protect classified information.
Thus, less frequent collection may endanger the United States common defense and national
security.

7.

Circumstances Which Justify Variation from the Office of Management and Budget
(OMB) Guidelines
There is no variation from OMB Guidelines in the collection of information.

8.

Consultations outside the NRC
Opportunity for public comment on the information collection requirements for this clearance

package was published in the Federal Register on April 8, 2019 (84 FR 13976). Two
comments were received from the public. In addition, NRC contacted four licensees and one
licensee provided a comment.
Comment 1:
An commenter expressed general support for the information collection, stating that it ensures
that individuals joining and leaving NRC understand their security responsibilities. The
commenter indicated that the burden estimate is reasonable but suggested that a secure web
form would be beneficial.
Response 1:
The NRC Form 176 is currently in NRC Forms Library and can be emailed to licensees,
contractors and others who may require use of the from. It is also accessible on NRC Public
Site. However, a secure website to obtain and submit the Form 176 is currently not
established, but the NRC, Division of Facilities and Security (DFS) is looking into the
matter. If a secure website can be established, NRC, DFS will work toward getting this
implemented.
Comment 2:
A commenter expressed general support for the information collection. He indicated that the
information collection is clear and concise; necessary; and provides the NRC with an
additional method to track access authorizations. He agreed with the published burden
estimate for the collection.
Response 2:
The NRC Form 176 is currently in NRC Forms Library and can be emailed to licensees,
contractors and others who may require use of the from. It is also accessible on NRC Public
Site. However, a secure website to obtain and submit the Form 176 is currently not
established, but the NRC, Division of Facilities and Security (DFS) is looking into the
matter. If a secure website can be established, NRC, DFS will work toward getting this
implemented.
Comment 3:
No comments on the burden of the form. I have not seen this form since I stated with the NRC
35 years ago. I believe the form is till relevant.
Several editorial comments are as follows: First bullet, "all SGI is unclassified." No need to say
"unclassified Safeguards..." Second bullet:
You may want to remove the words "sensitive unclassified" and replace it with "Controlled
Unclassified Information." Sixth bullet: I don't think the
term "designated countries" is no longer used. Not sure what is used today.
No documents available.
Response 3:
On the NRC Form 176A, in bullet 1, the phrase “unclassified safeguards” will be replaced with
“Controlled Unclassified Information”.
On the NRC Form 176A, in bullet 2, the phrase “sensitive unclassified information” will be
replaced with “Controlled Unclassified Information”.
On the NRC Form 176A, in bullet 6, the phrase “to designated countries” will be replaced with
“outside of the United States and its territories”.

9.

Payment or Gift to Respondents
Not Applicable.

10.

Confidentiality of the Information
Confidential and proprietary information is protected in accordance with NRC regulations at 10
CFR 9.17(a) and 10 CFR 2.390(b). However, no information normally considered confidential
or proprietary is requested.
Personal Information provided on the NRC Form 176 is handled and protected in
accordance with NRC directives and provisions of the Privacy Act of 1974, as described in
the Privacy Act Statement on the form. Information is maintained in a system of records
designated as NRC-39 and described in the Federal Register in NRC’s “Republication of
Systems of Records Notices” on November 17, 2016 (81 FR 81348).

11.

Justification for Sensitive Questions
There is no sensitive information requested on the NRC Form 176.

12.

Estimated Burden and Burden Hour Cost
The $275 hourly rate used in the burden estimates is based on the Nuclear Regulatory
Commission’s fee for hourly rates as noted in 10 CFR 170.20 “Average cost per professional
staff-hour.” For more information on the basis of this rate, see the Revision of Fee Schedules;
Fee Recovery for Fiscal Year 2018 (83 FR 29622, June 25, 2018).
An estimated 12 minutes (based on staff experience) is required to complete each NRC
Form 176. The NRC staff estimates that 400 responses will be received annually, resulting
in a total of annual burden to the public of 80 hours (400 responses x 12 minutes / 60). The
estimated annual cost is $22,000 (80 hours x $275 per hour).
NOTE: There is no record keeping requirement for contractors/licensees to maintain a
copy of the NRC Form 176.

13.

Estimate of Other Additional Costs
There are no additional costs.

14.

Estimated Annualized Cost to the Federal Government
The staff has developed estimates of cost to the Federal Government related to the conduct of
this information collection. These estimates are based on staff experiences and subject matter
expertise and include the burden needed to review, analyze and process the collected
information and any relevant operational expenses.
The estimated annual cost to the Federal Government associated with the NRC Form 176 is
22,053. The cost was computed as follows:
Total effort 400 forms X 12 minutes = 4800/60 = 80 hrs. X $275/hr.) = $22,000.00
Annual record holding
(1/4 cubic (cu) foot (ft.) X $212/cu. ft.)

=

$ 53.00

Total estimated annual cost to Federal government =

$22,053

This cost is fully recovered through fee assessment to NRC licensees pursuant to 10 CFR
Parts 170 and/or 171.
15.

Reasons for Changes in Burden or Cost
The NRC Form 136, “Security Termination Statement” and NRC Form 176, “Security
Acknowledgment,” is now combined into one form. The new form will be titled NRC Form 176,
“Security Acknowledgement and Termination Statement.” Modification to the form consisted
of adding from the NRC Form 136, “Security Termination Statement” number 3 and 4 to the
new NRC Form 176, “Security Acknowledgment and Termination Statement,” where they
became number 5 and 6 on the form. The last four SSN field has been added to the new
NRC Form 176 on page 1 and page 4 next to the date. Replaced unclassified safeguards
information within the form with Controlled Unclassified Information. Security Debriefing
Acknowledgement was added on the pages for the need of a signature. The cost has
increased due to a change in the fee rate from $268/hr. to $275/hr.

16.

Publications for Statistical Use
There is no application of statistics in the information collections related to NRC Form 176 and
no publication of the information.

17.

Reason for Not Displaying the Expiration Date
The expiration date is displayed on the form.

18.

Exceptions to the Certification Statement
Not Applicable.