Nrc Form 4 - Cumulative Occupational Dose History Page 2
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1
2INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 4
PRIVACY ACT STATEMENT
(All doses should be stated in rems)
1.
Type or print the full name of the monitored
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974
10.
Place an "X" in either Routine or PSE.
individual in the order of last name (include "Jr,"
Choose "Routine" if the data represent the
(Public Law 93-579), the following statement is furnished to individuals who supply
"Sr," "III," etc.), first name, middle initial (if
results of monitoring for routine exposures.
information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 4. This
applicable).
Choose "PSE" if the listed dose data
information is maintained in a system of records designated as NRC-27 and described at 69
represents the results of monitoring of
Federal Register 57601 (September 24, 2004), or the most recent Federal Register
planned special exposures received during the
2.
Enter the individual's identification number,
publication of the NRC's "Republication of Systems of Records Notices" that is available at
monitoring period.
including punctuation. This number should be
the NRC Public Document Room, 11555 Rockville Pike, Rockville, Maryland or located in
11.
the 9-digit social security number if at all
NRC's Agencywide Documents Access and Management System (ADAMS).
Enter the deep dose equivalent (DDE) to the
possible. If the individual has no social security
whole body.
number, enter the number from another official
12.
identification such as a passport or work permit.
Enter the eye dose equivalent (LDE) recorded
1.
AUTHORITY:
5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2073, 2093, 2095, 2111,
for the lens of the eye.
3.
Enter the code for the type of identification used
2133, 2134, and 2201(o); 10 CFR 20.2106, 20.2201-20.2204, and 20.2206; Executive
13.
as shown below:
Order 9397; Executive Order 12196.
Enter the shallow dose equivalent recorded for
the skin of the whole body (SDE,WB).
CODE ID TYPE
14.
2.
PRINCIPAL PURPOSE(S):
The information is used by the NRC in its evaluation of
SSN
U.S. Social Security Number
Enter the shallow dose equivalent recorded for
the risk of radiation exposure associated with the licensed activity and in exercising its
PPN
Passport Number
the skin of the extremity receiving the
CSI
Canadian Social Insurance Number
statutory responsibility to monitor and regulate the safety and health practices of its
maximum dose (SDE,ME).
WPN Work Permit Number
licensees. The data permits a meaningful comparison of both current and long-term
15.
PADS PADS Identification Number
exposure experience among types of licensees and among licensees within each type.
Enter the committed effective dose equivalent
OTH
Other
(CEDE).
Data on your exposure to radiation is available to you upon your request.
16.
4.
Check the box that denotes the sex of the
Enter the committed dose equivalent (CDE)
The information may be used to provide data to other Federal and
individual being monitored.
3.
ROUTINE USE(S):
recorded for the maximally exposed organ.
State agencies involved in monitoring and/or evaluating radiation exposure received by
17.
5.
Enter the date of birth of the individual being
individuals monitored for radiation exposure while employed by or visiting or temporarily
Enter the total effective dose equivalent
monitored in the format MM/DD/YYYY.
(TEDE). The TEDE is the sum of items 11 and
assigned to certain NRC licensed facilities; to return data provided by licensee upon
18.
15.
request. The information may also be disclosed to an appropriate Federal, State, local
6.
Enter the monitoring period for which this report
or Foreign agency in the event the information indicates a violation or potential violation
is filed. The format should be MM/DD/YYYY -
Enter the total organ dose equivalent (TODE)
MM/DD/YYYY.
of law and in the course of an administrative or judicial proceeding. In addition, this
for the maximally exposed organ. The TODE
information may be transferred to an appropriate Federal, State, local and Foreign
19.
is the sum of items 11 and 16.
7.
Enter the name of the licensee or facility not
agency to the extent relevant and necessary for an NRC decision about you or to the
licensed by NRC that provided monitoring.
Signature of the monitored individual. The
extend relevant and necessary for that agency's decision about you. Information from
signature of the monitored individual on this
this form may also be disclosed, in the course of discovery and in presenting evidence,
8.
Enter the NRC license number or numbers.
form indicates that the information contained
to a Congressional office to respond to their inquiry made at your request, or to
on the form is complete and correct to the best
9.
Place an "X" in Record, Estimate, or No Record.
NRC-paid experts, consultants, and others under contract with the NRC, on a
20.
of his or her knowledge.
Choose "Record" if the dose data listed
need-to-know basis.
represent a final determination of the dose
Enter the date this form was signed by the
4.
received to the best of the licensee's
21.
monitored individual.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
knowledge. Choose "Estimate" only if the listed
INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the
dose data are preliminary and will be
[OPTIONAL] Enter the name of the licensee or
superseded by a final determination resulting in
requested information, including social security number (identification number). The
facility not licensed by NRC, providing
a subsequent report. An example of such an
monitoring for exposure to radiation (such as a
social security number is used to assure that NRC has an accurate identifier not subject
instance would be dose data based on
DOE facility) or the employer if the individual is
to the coincidence of similar names or birth dates among the large number of persons
self-reading dosimeter results and the licensee
not employed by the licensee and the
on who data is maintained and to assure that there are no missed doses or monitoring
intends to assign the record dose on the basis
employer chooses to maintain exposure
periods and an individual gets a complete dose history when requested. The licensee
of TLD results that are not yet available. If the
22.
records for its employees.
must complete NRC Form 5 on each individual for whom personnel monitoring is
individual or an organization has indicated that
[OPTIONAL] Signature of the person
the individual was monitored, but the monitoring
required under 10 CFR 20.2106. Failure to do so may subject the licensee to
designated to represent the licensee or
records could not be obtained, enter "No
enforcement action in accordance with 10 CFR 20.2401..
employer entered in item 21. The licensee or
Record" for this monitoring period. The
5.
employer who chooses to countersign the form
individual would not be available for a PSE. For
SYSTEM MANAGER(S) AND ADDRESS: REIRS Project Manager, Radiation
should have on file documentation of all the
monitoring periods during the current year
23.
information on the NRC Form 4 being signed.
Protection, Environmental Risk, and Waste Management Branch, Division of Systems
where records are not available, reduce the
individual's allowable dose by 1.25 rems for
Analysis and Regulatory Effectiveness, Office of Nuclear Regulatory Research, U.S.
[OPTIONAL] Enter the date this form was
each quarter for which records were unavailable
Nuclear Regulatory Commission, Washington, DC 20555-0001.
signed by the designated representative.
as required by 10 CFR 20.2104(e)(1).
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