DOE F 470.4 Acknowledgement and Agreement to Participate In The Huma

DOE F 470.4 (06/2023)
PREVIOUS EDITIONS ARE OBSOLETE

U.S. DEPARTMENT OF ENERGY
ACKNOWLEDGMENT AND AGREEMENT TO PARTICIPATE
IN THE HUMAN RELIABILITY PROGRAM (HRP)

OMB Control No. 1910-5122
Expiration Date:

PRIVACY ACT STATEMENT
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of
Energy (DOE) to regulate the possession and use of special nuclear material and access to restricted data. DOE will use the
information collected on this form to aid in the determination of an individual’s eligibility for an HRP certification. The information
may also be provided to other agencies of the United States government for investigations that involve protection of the national
security, public health and safety, or the environment. Submission of the information requested on this form is voluntary, but failure
to provide the information may result in denial of an HRP certification. If DOE uses the information for purposes other than those
indicated in this statement, it will provide notice of those additional purposes to persons who have submitted information on this
form. This statement is in reference to the relevant System of Records Notice (SORN) per Circular A-108, DOE-50, HRP Records
SORN 230104 (https://www.federalregister.gov/documents/2009/01/09/E8-31316/privacy-act-of-1974-publication-of-compilationof-privacy-act-systems-of-records).
OMB BURDEN DISCLOSURE STATEMENT
This data is being collected as an acknowledgment and agreement to participation in the Human Reliability Program. The data you
supply will be used to ensure that individuals who occupy positions affording access to certain materials, nuclear explosive devices,
facilities, and programs meet the highest standards of reliability and physical and mental suitability. Public reporting burden for this
collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Information
Collection Management Program (1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585;
and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5122), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for
failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection
of information displays a currently valid OMB control number. Submission of this data is mandatory.
SECTION I. CONSENT
1. I, _________________________________________, acknowledge that I am seeking to occupy or retain an HRP position.
2. I recognize that the Department of Energy (DOE) has the highest of national security, safety, and public health interests in
assuring that individuals occupying HRP positions meet the highest standards of human reliability.
3. I acknowledge that I have been advised of the requirements for occupying, or continuing to occupy, a HRP position. I have also
been advised of my responsibilities under the program. The HRP components, including supervisory review, medical assessment,
psychological examination, testing for the use of illegal drugs, random alcohol testing, management recommendation, and the
DOE security review and clearance determination, have been fully explained to me.
4. I hereby consent and agree to submit to all components under the HRP and further consent and agree to cooperate fully
with___________________________________________ (contractor) and/or the DOE in the assessment of my eligibility or
certification to an HRP position.
SECTION II. PARTICIPANT SIGNATURE
5. Name:

6. Signature:

7. Date:

SECTION III. HRP MANAGEMENT OFFICIAL SIGNATURE
8. Name:

DOE F 470.4 (06/2023)

9. Signature:

10. Date:

Section 508 Compliant