Nrc Form 4 - Cumulative Occupational Dose History

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PAGE
OF
NRC FORM 4
U.S. NUCLEAR REGULATORY COMMISSION
APPROVED BY OMB NO.3150-0005
EXPIRES: 09/30/2007
(9-2004)
Estimated burden per response to comply with this mandatory collection request: 30 minutes. This
10 CFR PART 20
information is required to record an individual's lifetime occupational exposure to radiation to ensure that
the cumulative exposure to radiation does not exceed regulatory limits. Send comments regarding burden
estimate to the Records and FOIA/Privacy Services Branch (T-5 F52), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by internet e-mail to infocollects@nrc.gov, and to the Desk
CUMULATIVE OCCUPATIONAL DOSE HISTORY
Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0005), Office of Management
and Budget, Washington, DC 20503. If a means used to impose an information collection does not display
a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required
to respond to, the information collection.
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
5. DATE OF BIRTH
(MM/DD/YYYY)
MALE
FEMALE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11. DDE
12. LDE
13. SDE, WB
14. SDE, ME
15. CEDE
16. CDE
17. TEDE
18. TODE
19. SIGNATURE OF MONITORED INDIVIDUAL
20. DATE SIGNED
21. CERTIFYING ORGANIZATION
22. SIGNATURE OF DESIGNEE
23. DATE SIGNED
NRC FORM 4 (9-2004)
PRINTED ON RECYCLED PAPER

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