Information Collection

NRC Form 176, Security Acknowledgment and Termination Statement.

IC 236852 under ICR 202511-3150-004 · OMB 3150-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement.	Form and Instruction
Form NRC Form 176 Security Acknowledgement and Termination Statement NRC Form 176, Security Acknowledgment and Termination Statement.	Form and Instruction
NRC Form 176 Security Acknowledgement and Termination Statement NRC 176 (OMB Copy 4) (09-15-2025) New Wording OGC - Updated by CH Apvd by LS.pdf	Form and Instruction
NRC Form 176 Security Acknowledgement and Termination Statement NRC 176 (OMB Copy 4) (09-15-2025) New Wording OGC - Updated by CH Apvd by LS.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 10 CFR 9

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 176				Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: NRC-39, Personnel Security Files and Associated Records-NRC

FR Citation: 77 FR 22561

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000	600	400
Annual IC Time Burden (Hours)	200	120	80
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].