Form NRC Form 4 NRC Form 4 Cumulative Occupational Dose History

PAGE _____ OF _____
NRC FORM 4

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)
10 CFR PART 20

Estimated burden per response to comply with this mandatory collection request: 15 minutes. This information is required
to record an individual’s lifetime occupational exposure to radiation to ensure that the cumulative exposure to radiation
does not exceed regulatory limits. 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 the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0005), Attn: Desk Officer for the
Nuclear Regulatory Commission, 725 17Street NW, Washington, DC 20503; e-mail: [email protected].
The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
document requesting or requiring the collection displays a currently valid OMB control number.

CUMULATIVE OCCUPATIONAL DOSE HISTORY
*Note: Social Security Numbers must not be visible on the outside of any package sent by mail.
1. NAME (LAST, FIRST, MIDDLE INITIAL)

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB NO. 3150-0005

2. IDENTIFICATION NUMBER*

3. ID TYPE

4. SEX

5. DATE OF BIRTH
(MM/DD/YYYY)

MALE
FEMALE

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

7. LICENSEE NAME

9.

8. LICENSE NUMBER

11a. EDEX

11b. DDE

13. SDE,WB

14. SDE,ME

7. LICENSEE NAME

15. CEDE

16. CDE

17. TEDE

9.

8. LICENSE NUMBER

13. SDE,WB

14. SDE,ME

7. LICENSEE NAME

15. CEDE

16. CDE

8. LICENSE NUMBER

9.

13. SDE,WB

14. SDE,ME

7. LICENSEE NAME

15. CEDE

16. CDE

9.

8. LICENSE NUMBER

13. SDE,WB

14. SDE,ME

7. LICENSEE NAME

15. CEDE

16. CDE

PSE

RECORD

10.

8. LICENSE NUMBER

9.

18. TODE

RECORD

10.

13. SDE,WB

14. SDE,ME

7. LICENSEE NAME

15. CEDE

16. CDE

8. LICENSE NUMBER

17. TEDE

9.

-

18. TODE

RECORD

10.

ESTIMATE

13. SDE,WB

14. SDE,ME

15. CEDE

20. DATE SIGNED

21. CERTIFYING ORGANIZATION

16. CDE

17. TEDE

22. SIGNATURE OF DESIGNEE

ROUTINE
PSE

NO RECORD

12. LDE

ROUTINE
PSE

NO RECORD

12. LDE

ROUTINE
PSE

ESTIMATE

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

NRC FORM 4 (MM-YYYY)

ROUTINE

18. TODE

17. TEDE

-

19. SIGNATURE OF MONITORED INDIVIDUAL

10.

NO RECORD

12. LDE

11b. DDE

RECORD

ESTIMATE

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

11a. EDEX

PSE

18. TODE

17. TEDE

-

11b. DDE

ROUTINE

NO RECORD

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

11a. EDEX

10.

ESTIMATE

12. LDE

11b. DDE

RECORD

17. TEDE

-

11a. EDEX

18. TODE

NO RECORD

12. LDE

11b. DDE

PSE

ESTIMATE

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

11a. EDEX

ROUTINE

NO RECORD

12. LDE

11b. DDE

10.

ESTIMATE

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)

11a. EDEX

RECORD

18. TODE

23. DATE SIGNED

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 4
(All doses should be stated in rems)
11A. EDEX – Enter the EDEX for the entire monitoring period
(e.g., year). EDEX is the sum of the EDEX component
determined using NRC-approved special dosimetry methods
(see RG 8.40) and the EDEX component estimated by the
2. Enter the individual’s identification number, do not include
DDE for those time periods when not using NRC-approved
punctuation. This number should be the 9-digit social
special dosimetry methods.
security number if at all possible. If the individual has no
social security number, enter the number from another
Note: If EDEX has been determined by measuring the DDE
official identification such as a passport or work permit.
(at the highest exposed part of the whole body – see 10 CFR
20.1201(c)) for the entire monitoring period, then box 11a
3. Enter the code for the type of identification used as shown
and 11b will have the same value.
below:
1. Type or print the full name of the monitored individual in
the order of last name (include “Jr,” “Sr,” “III,” etc.), first
name, middle initial (if applicable).

CODE ID TYPE
SSN

U.S. Social Security Number

PPN

Passport Number

CSI

Canadian Social Insurance Number

WPN

Work Permit Number

PADS

PADS Identification Number

OTH

Other

11B. DDE – Enter the DDE measured at the highest point on the
whole body for the entire monitoring period (e.g.,year –
including those time periods when EDEX was being
determined using NRC-approved special dosimetry
methods).
12.

Enter the eye dose equivalent (LDE) recorded for the lens of
the eye.

13. Enter the shallow dose equivalent recorded for the skin
of the whole body (SDE,WB).

4. Check the box that denotes the sex of the individual being
14. Enter the shallow dose equivalent recorded for the skin of the
monitored.
extremity receiving the maximum dose (SDE,ME).
5. Enter the date of birth of the individual being
15. Enter the committed effective dose equivalent (CEDE).
monitored in the format (MM/DD/YYYY).
6. Enter the monitoring period for which this report is filed.
The format should be (MM/DD/YYYY) - (MM/DD/YYYY).

16. Enter the committed dose equivalent (CDE) recorded for the
maximally exposed organ.

7. Enter the name of the licensee or facility not licensed by
NRC that provided monitoring.

17. Enter the total effective dose equivalent (TEDE). The TEDE
is the sum of items 11a and 15.

8. Enter the NRC license number or numbers.

18. Enter the total organ dose equivalent (TODE) for the
maximally exposed organ. The TODE is the sum of items
11b and 16.

9. Place an “X” in Record, Estimate, or No Record. Choose
“Record” if the dose data listed represent a final
determination of the dose received to the best of the
licensee’s knowledge. Choose “Estimate” only if the listed
dose data are preliminary and will be superseded by a
final determination resulting in a subsequent report. An
example of such an instance would be dose data based
on self-reading dosimeter results and the licensee intends
to assign the record dose on the basis of TLD results that
are not yet available. If the individual or an organization
has indicated that the individual was monitored, but the
monitoring records could not be obtained, enter “No
Record” for this monitoring period. The individual would
not be available for a PSE. For monitoring periods during
the current year where records are not available, reduce
the individual’s allowable dose by 1.25 rems for each
quarter for which records were unavailable as required by
10 CFR 20.2104(e)(1).
10. Place an “X” in either Routine or PSE. Choose “Routine”
if the data represent the results of monitoring for routine
exposures. Choose “PSE” if the listed dose data
represents the results of monitoring of planned special
exposures received during the monitoring period.

19. Signature of the monitored individual. The signature of the
monitored individual on this form indicates that the
information contained on the form is complete and correct to
the best of his or her knowledge.
20. Enter the date this form was signed by the monitored
individual.
21. [OPTIONAL] Enter the name of the licensee or facility not
licensed by NRC, providing monitoring for exposure to
radiation (such as a DOE facility) or the employer if the
individual is not employed by the licensee and the employer
chooses to maintain exposure records for its employees.
22. [OPTIONAL] Signature of the person designated to represent
the licensee or employer entered in item 21. The licensee or
employer who chooses to countersign the form should have
on file documentation of all the information on the NRC
Form 4 being signed.
23. [OPTIONAL] Enter the date this form was signed by the
designated representative.

PRIVACY ACT STATEMENT
NRC FORM 4
CUMULATIVE OCCUPATIONAL DOSE HISTORY
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 4. This information is maintained in a system of records
designated as NRC-27 and described at 81 Federal Register 81340 (November 17, 2016), or the most
recent Federal Register publication of the NRC's Systems of Records Notices that is located in NRC's
Agencywide Documents Access and Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2051, 2073, 2093, 2095, 2111, 2133, 2134,
and 2201(o); 10 CFR Parts 20 and 34; Executive Order (E.O.) 9397, as amended by E.O. 13478; E.O.
12196, as amended; E.O. 13708.
2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the risk of
exposures to radiation and radioactive material associated with licensed activities and in exercising its
statutory responsibility to monitor and regulate the safety and health practices of its licensees. The data
permits a meaningful comparison of both current and long-term exposure experience among types of
licensees and among licensees within each type. Data on your exposure to radiation is available to you
upon your request.
3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act,
information may be used to provide data to other Federal and State agencies involved in monitoring and/
or evaluating radiation exposure received by individuals monitored for radiation exposure while employed
by or visiting or temporarily assigned to certain NRC licensed facilities; and to return data provided by
licensee upon request. 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; in the course
of an administrative or judicial proceeding; 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; 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; to NRC-paid experts, consultants, and others under contract with the NRC, on a
need-to-know basis; or to appropriate persons and entities for purposes of response and remedial efforts
in the event of a suspected or confirmed breach of data from this system of records.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF
NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information, including
the Social Security number (SSN) in block #2. The SSN is used to assure that NRC has an accurate and
unique identifier not subject to the coincidence of similar names or birth dates among the large number of
persons on who data is maintained and to assure that there are no missed doses or monitoring periods
and an individual gets a complete dose history when requested. The licensee must complete NRC Form
5 on each individual for whom personnel monitoring is required under 10 CFR 20.1502. In addition,
licensees must submit this information to NRC in accordance with the requirement under 10 CFR
20.2206. Failure to do so may subject the licensee to enforcement action in accordance with 10 CFR
20.2401.
5. SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection Branch,
Division of Systems Analysis, Office of Nuclear Regulatory Research, U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001.