Form Online NRC ONLINE FORM, “REQUEST FOR ALTERNATIVE UNDER 10 CFR P

Request for Alternative under 10 CFR
50.55a(z)(1) and 10 CFR 50.55a(z)(2)
Consistent with the NRC regulations, please provide required copies to state and other government agencies,
and the NRC regional office.
APPROVED BY OMB NO.

Expiration Date:

Estimated burden per response to comply with this collection request: 2 hours. This form is used to submit
COVID-19 related requests for an exemption from certain requirements in 10 CFR Part 50.55a. 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 [email protected]. and to the Desk
Officer, Office of Information and Regulatory Affairs, NEOB-10202 (3150-0018), Office of Management and
Budget, Washington, DC 20503. If a means used to impose an information collection does not display a
current valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to
respond to, the information collection.

* Required

Application
1. Title of Project: *
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2. Licensee: *
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3. Licensee Contact: *

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4. Licensee Contact Phone Number: *
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5. Licensee Contact Email Address: *
Please enter the email address for which you would like to receive communications regarding this request.
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6. Plant Identification Number (PIN): *
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7. Plant Name:
Select your answer

8. Plant Unit(s):
1
2
3
4

9. Docket Number(s):
Example: 05000313



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10. License Number(s):
Example: DPR-51
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11. Requested Completion Date:
Please input date in format of M/d/yyyy

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12. Applicable Regulation and Inservice Inspection (ISI) or Inservice Testing (IST):
10 CFR 50.55a(z)(1) ISI
10 CFR 50.55a(z)(1) IST
10 CFR 50.55a(z)(2) ISI
10 CFR 50.55a(z)(2) IST

13. Proposed Alternative Number or Identifier:
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14. Applicable American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel (BPV)
Code, or ASME Operations and Maintenance (OM) Code, Edition and Addenda:

Enter your answer

15. ISI or IST Program Interval Number and start/end dates (as applicable):
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16. ASME Code Class:
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17. Applicable Components and/or System Description (if applicable):
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18. Describe the Applicable Code Requirements:
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19. Reason for Request:
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20. Brief Description of the Proposed Alternative (500 characters or less):
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21. Full Description of the Proposed Alternative:
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22. If needed, include additional information for Question 20:
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23. Description of the Basis for Use:
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24. If needed, include additional information for Question 22:
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25. If requesting an alternative based on 10 CFR 50.55a(z)(2), describe hardship or unusual
difficulty without compensating increase in the level of quality and safety associated with
compliance with applicable code requirement. For requests under 10 CFR 50.55a(z)(1), leave
this section blank.
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26. Proposed duration of the alternative:
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27. Include any additional information, as necessary:
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28. Precedents (optional):
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29. References:
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30. Do you have attachments? *

Yes
No

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