Form NRC Form 176 NRC Form 176 SECURITY ACKNOWLEDGMENT

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 176

(MM-YYYY)
NRC MD 12.3

A. SECURITY ACKNOWLEDGMENT

APPROVED BY OMB: NO. 3150-XXXX

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory information collection request: XX
minutes. This submittal is used by NRC to initiate termination of access authorization. Send
comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.
gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202,
(3150-0049), 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.

INSTRUCTIONS: Applicants for U.S. Nuclear Regulatory Commission (NRC) Access Authorization (Security Clearance),
Complete Section A. and C.
Applicants for Special Nuclear Material Access Authorization (employees of licensed organizations or other
individuals affected by 10 CFR Part 11). Complete Section B. and C.
I,
, in anticipation of my access authorization by the United States Nuclear Regulatory
Commission (NRC), make the following statement with the understanding and intent that my statement will be used by the NRC in carrying
out its obligation to protect the security of Restricted Data and Controlled Unclassified Information.
1. I understand that it is the policy of the NRC to control the dissemination of Restricted Data, and Controlled Unclassified Information
(e.g., privacy information, Safeguards Information, and proprietary information) in such a manner as to assure the common defense
and security.
2. I understand that, in carrying out this policy, the NRC has issued and will issue and revise, as circumstances require, certain
instructions and regulations pertaining to the control and dissemination of Restricted Data, and Controlled Unclassified information.
3. I shall not unlawfully reveal to any person any Restricted Data, or Controlled Unclassified Information, of which I may gain knowledge
as a result of my employment assignment, or duties, except as authorized by law, regulations of the NRC, or in writing by officials of
the NRC empowered to grant permission for such disclosure.
4. I am aware that the Atomic Energy Act of 1954, as amended, U.S. Code, Title 18, "Crimes and Criminal Procedures," and 32 Code of
Federal Regulations, Part 2002, "Controlled Unclassified Information” prescribe penalties for unauthorized disclosure of Restricted
Data, Formerly Restricted Data, Controlled Unclassified Information, and other information relating to the national defense, and for
loss, destruction or compromise of such information through gross negligence.
5. I am aware that, unless and until I am released in writing by an authorized representative of the U.S. Government, all conditions and
obligations imposed upon me by virtue of my having executed SF 189, “Classified Information Nondisclosure Agreement,” or SF 312
of the same title, remain in full force and effect.
6. I am aware that I may be liable for damages if I reveal to any unauthorized person Controlled Unclassified information (e.g., privacy
information, proprietary information) of which I have gained Knowledge as a result of my employment, affiliation with NRC.
7. I understand that revealing or disclosing Restricted Data or Controlled Unclassified Information, to any unauthorized personnel
constitute sufficient cause for termination or my association with the NRC.
8. I understand that the NRC desires to be informed when persons granted NRC security clearance propose to travel outside of the
United States and its territories NRC wishes to be advised of such travel in order to inform the individual of the possible risks to
personal safety in view of the classified information known to the individual. Informing the NRC of travel outside of the United States
and its territories does not apply to individuals who obtain an NRC security clearance and receive access to NRC classified information
solely as employees of other Government agencies or their contractors.
9. I am aware that I may be subject to criminal penalties if I make any statement of material facts on my personnel security forms or
related information in application for my NRC security clearance knowing that such statement is false or if I willfully conceal any
material fact (Title 18, U.S. Code, Section 1001).
10. I understand that I am to comply with all reporting requirements. I agree to notify the NRC, Division of Facilities and Security, within 5
days of reportable information as set forth in Security Executive Agent Directive (SEAD 3) or other applicable guidance, including but
not limited to, arrests, charges (INCLUDING CHARGES THAT ARE DISMISSED) or detentions by Federal State or other law
enforcement authorities, for any violation of any Federal, military, State, county or municipal law, regulation or ordinance other than
minor traffic violations for which a fine of $150 or less was imposed, occurring during any period in which I may hold NRC security
clearance or which occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or
Standard Form 86C, "The Standard Form 86 Certification."
Date

Social Security Number (Last 4 digits)

City and State where Signed

NRC FORM 176 (MM-YYYY)

Signature

Name of Employer

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 176
(MM-YYYY)

NRC MD 12.3

B. SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION ACKNOWLEDGMENT

I,
, in anticipation of my special nuclear material access authorization ("U" or "R") by
the United States Nuclear Regulatory Commission (NRC), make the following statement with the understanding and intent that my
statement will be used by the NRC in carrying out its obligation to assure the control and safeguarding of special nuclear material in
accordance with the terms of the Atomic Energy Act of 1954, as amended. I understand that:
1. It is the policy of the NRC to regulate access to, and provide for control over, special nuclear material in such a manner as to provide
high assurance that activities involving such materials are not inimical to the common defense and security and do not constitute an
unreasonable risk to the public health and safety.
2. I understand, that in carrying out this policy, the NRC has issued, and will issue and revise as circumstances require, certain
instructions and regulations pertaining to access to and control of special nuclear material.

3. Any theft or other unlawful diversion of special nuclear material, or any attempt or conspiracy to steal, or unlawfully divert such
material, is a criminal violation of the Atomic Energy Act of 1954, as amended, and subject to criminal penalties.
4. I am prohibited from providing direct or indirect assistance in the development or production of special nuclear material outside of the
United States, to include technology transfers and assistance related to certain nuclear fuel-cycle activities, commercial nuclear power
plants, and research and test reactors, unless authorized by the Secretary of Energy and/or the U.S. Nuclear Regulatory Commission
in accordance with the requirements of Atomic Energy Act of 1954, as amended, and 10 CFR Part 810. I understand that this
prohibition is on-going and applies to my activities and employment upon leaving the NRC, and includes transfer of physical
documents, electronic media or transfers, and/or knowledge and expertise. Violation of this prohibition could subject me to criminal
penalties.
5. I understand that I am to notify the NRC, Division of Facilities and Security, within 5 days of all arrests, charges (INCLUDING
CHARGES THAT ARE DISMISSED) or detentions by Federal, State or other law enforcement authorities, for any violation of any
Federal, military, State, county or municipal law, regulation or ordinance other than minor traffic violations for which a fine of $150 or
less was imposed, occurring during any period in which I may hold an NRC special nuclear material access authorization or which
occurred subsequent to the completion of Standard Form 86, "Questionnaire for National Security Positions," or Standard Form 86C,
"The Standard Form 86 Certification."

Date

Social Security Number (Last 4 digits)

City and State Where Signed

NRC FORM 176 (MM-YYYY)

Signature

Name of Employer

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 176
(MM-YYYY)
10CFR11

C. SECURITY DEBRIEFING ACKNOWLEDGEMENT
I reaffirm that the provisions of the espionage laws, other federal criminal laws and executive orders
applicable to the safeguarding of classified information, Restricted Data, National Security Information,
or Controlled Unclassified Information, have been made available to me; I have returned or
destroyed, in accordance with NRC security regulations, all classified and/or sensitive information which
I may have had in my custody; I will not communicate or transmit classified information to any
unauthorized person or organization; I will promptly report to the Federal Bureau of Investigation
any attempt by an unauthorized person to solicit classified information, and

I Have Received A Security Debriefing.

Date

Social Security Number (Last 4 digits)

Typed or Printed Name of Witness

I Have Not Received A Security Debriefing.

Signature of Employee

Signature of Witness

PRIVACY ACT STATEMENT
SECURITY ACKNOWLEDGMENT/SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION
ACKNOWLEDGMENT
NRC FORM 176
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 176. This information is maintained in a system of records designated as
NRC-39 and described at 81 Federal Register 81348 (November 17, 2016), or the most recent Federal
Register publication of the NRC's “Republication of Systems of Record 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, 2001(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. 13467; E E.O. 13526, E.O. 13587; 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): An individual's signature on this form initiates action to terminate his/her
access authorization and indicates an individual's acknowledgment/acceptance of continuing responsibilities
following the termination of their access authorization and/or employment for the protection of classified and
sensitive unclassified information that individual had access to in the course of performing official duties.
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 NRCpaid 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, non-receipt
of this signed form may result in a failure to terminate an individual's access authorization.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of
Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.