NRC Form 176 - Security Acknowledgment and Termination Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement.	Form and Instruction	Modified	Repair queued
2022-17811.pdf	Supplementary Document	Uploaded 2022-08-19	Repair queued
30-day Supporting Statement ML22158A099 (1).pdf	Supporting Statement A	Uploaded 2022-08-18	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
236852	NRC Form 176, Security Acknowledgment and Termination Statement.	Form and Instruction	Modified

ICR Details

OMB Control No: 3150-0239	ICR Reference No: 202208-3150-007
Status: Received in OIRA	Previous ICR Reference No: 201907-3150-004
Agency/Subagency: NRC	Agency Tracking No:
Title: NRC Form 176 - Security Acknowledgment and Termination Statement
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/19/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2022
Responses	400	400
Time Burden (Hours)	80	80
Cost Burden (Dollars)	0	0

---

Abstract: The NRC Form 176, “Security Acknowledgment and Termination Statement” is completed by employees, licensees and contractors in connection with the termination of their access authorization/security clearance granted by the NRC and to acknowledgment and accept their continuing security responsibility.

---

Authorizing Statute(s): EO: EO 12958 Name/Subject of EO: Section 4.3
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 19982	04/06/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 51161	08/19/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
NRC Form 176, Security Acknowledgment and Termination Statement.	NRC Form 176	Security Acknowledgment and Termination Statement

---

ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400	400	0	0	0	0
Annual Time Burden (Hours)	80	80	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $23,040

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/19/2022

---