NRC Form 176 - Security Acknowledgment and Termination Statement

OMB 3150-0239

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.

The latest form for NRC Form 176 - Security Acknowledgment and Termination Statement expires 2022-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction
2022-17811.pdf Supplementary Document
30-day Supporting Statement ML22158A099 (1).pdf Supporting Statement A
NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction

All Historical Document Collections

202208-3150-007 Approved without change	Extension without change of a currently approved collection	2022-08-19
201907-3150-004 Approved with change	New collection (Request for a new OMB Control Number)	2019-07-11