Form NRC Form 176 NRC Form 176 Security Acknowledgement and Termination Statement

NRC FORM 176

U.S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)
NRC MD 12.3

A. SECURITY ACKNOWLEDGMENT
*Note: Social Security Numbers must not be visible on the outside of any package sent by mail.

APPROVED BY OMB: NO. 3150-0239

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory information collection request: 12 minutes. This submittal
is used by NRC to initiate termination of access authorization. Send comments regarding burden estimate to the FOIA,
Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC
20555-0001, or by email to [email protected], and the OMB reviewer at: OMB Office of Information and
Regulatory Affairs, (3150-0239), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW,
Washington, DC 20503. 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.

INSTRUCTIONS: Applicants for U.S. Nuclear Regulatory Commission (NRC) Access Authorization, Complete Section A (prior to access
and C (when exiting the NRC).
Applicants for Special Nuclear Material Access Authorization (employees of licensed organizations or other individuals
affected by 10 CFR Part 11). Complete Section B (prior to access) and C (when exiting the NRC).
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 access to and the dissemination of Restricted Data, and Controlled Unclassified
Information (e.g., federal automated information systems/data, privacy information, Safeguards Information, 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 loss, 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
impose 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 Restricted Data and Controlled Unclassified Information of
which I have gained knowledge as a result of my affiliation with the 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 must be informed when personnel granted NRC access authorization propose to travel for unofficial purposes
outside of the United States and its territories. Unofficial foreign travel must be reported to Office of Administration/Division of Facilities and
Security, Management and Operations Branch. 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 I must report any criminal conduct including arrests, charges (even if dismissed), allegations or admissions of criminal conduct,
and/or detentions by Federal, State, or other law enforcement authorities for any violation of a Federal, military, State, county, or municipal law,
regulation, or ordinance--excluding only minor traffic violations for which a fine of $300 or less was imposed--occurring during any period in
which they hold an NRC security clearance.

11.

I understand that: A. These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations,
rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the
reporting to an Inspector General or the Office of Special Counsel of a violation of any law, rule, or regulation, or mismanagement, a gross
waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection.
The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are
incorporated into this agreement and are controlling.; or, B. prohibits or restricts an employee or applicant for employment from disclosing to
Congress, the Special Counsel, the Inspector General of an agency, or any other agency component responsible for internal investigation or
review any information that relates to any violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of
authority, or a substantial and specific danger to public health or safety, or any other whistleblower protection.

Date

Social Security Number (Last 4 digits)

City and State where Signed

NRC FORM 176 (MM-DD-YYYY)

Signature

Name of Employer

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 176
(MM-DD-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, Personnel Security Branch, 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."

6. I understand that: A. These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or
liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an
Inspector General or the Office of Special Counsel of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of
authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements,
obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are
controlling.; or, B. prohibits or restricts an employee or applicant for employment from disclosing to Congress, the Special Counsel, the Inspector General
of an agency, or any other agency component responsible for internal investigation or review any information that relates to any violation of any law, rule,
or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or any
other whistleblower protection.

Date

Social Security Number (Last 4 digits)

City and State Where Signed

NRC FORM 176 (MM-DD-YYYY)

Signature

Name of Employer

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U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 176
(MM-DD-YYYY)
NRC MD 12.3

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, sensitive information, Controlled Unclassified
Information and/or agency property which I may have had in my custody; I will not communicate or
transmit classified information or Controlled Unclassified 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.

Typed or Printed Name of Employee

Signature and Date - Employee

Typed or Printed Name of Witness

Signature and Date - Witness

NRC FORM 176 (MM-DD-YYYY)

I Have Not Received A Security Debriefing.

Social Security Number (Last 4 digits)

Page 3

PRIVACY ACT STATEMENT
SECURITY ACKNOWLEDGMENT/SPECIAL NUCLEAR MATERIAL ACCESS AUTHORIZATION
ACKNOWLEDGMENT
NRC FORM 176
Pursuant to 5 U.S.C. 552(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 Nuclear Regulatory
Commission (NRC) on NRC Form 176. This information is maintained in a system of records designated as
NRC-39 and described at 89 Federal Register 58792 (July 19, 2024), or the most recent Federal Register
publication of the NRC's "Republication of Systems of Records Notices" that is located in NRC's Agencywide
Documents Access and Management System (ADAMS).
1. AUTHORITY: 42 U.S.C. 2011 et seq.; 42 U.S.C. 2165, 2201(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.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): To determine your initial or continuing eligibility for NRC access to Restricted
Data, National Security Information, other Classified Information, and Controlled Unclassified Information;
access to or control over special nuclear material; or access to federal automated information systems or data.

3. ROUTINE USE(S): Information in these records may be used by the Division of Facilities and Security and
on a need-to-know basis by appropriate NRC officials, Hearing Examiners, Personnel Security Review Panel
members, Office of Personnel Management, Central Intelligence Agency, and other Federal agencies to
determine clearance or access authorization eligibility; to determine eligibility for access to NRC buildings or
access to Federal automated information systems or data; to certify clearance or access authorization; to
maintain the NRC personnel security program; and to provide licensees information needed for unescorted
access or access to safeguard 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; 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 needto-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: Disclosure of this information is voluntary; however, if it is not supplied, your
access authorization may be delayed or denied.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of
Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.