View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
3150-0239
ICR Reference No:
201907-3150-004
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
NRC
Agency Tracking No:
Title:
NRC Form 176 - Security Acknowledgment and Termination Statement
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
10/24/2019
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/11/2019
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2022
36 Months From Approved
Responses
400
0
0
Time Burden (Hours)
80
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
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.
Authorizing Statute(s):
EO: EO 12958 Name/Subject of EO: Section 4.3
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
84 FR 13976
04/08/2019
30-day Notice:
Federal Register Citation:
Citation Date:
84 FR 32480
07/08/2019
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
NRC Form 176, Security Acknowledgment and Termination Statement.
NRC Form 176
SECURITY ACKNOWLEDGMENT
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
400
0
0
0
400
0
Annual Time Burden (Hours)
80
0
0
0
80
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The NRC Form 136, “Security Termination Statement” and NRC Form 176, “Security Acknowledgment,” is now combined into one form. The new form will be titled NRC Form 176, “Security Acknowledgement and Termination Statement.” Modification to the form consisted of adding from the NRC Form 136, “Security Termination Statement” number 3 and 4 to the new NRC Form 176, “Security Acknowledgment and Termination Statement,” where they became number 5 and 6 on the form. The last four SSN field has been added to the new NRC Form 176 on page 1 and page 4 next to the date. Replaced unclassified safeguards information within the form with Controlled Unclassified Information. Security Debriefing Acknowledgement was added on the pages for the need of a signature. The cost has increased due to a change in the fee rate from $268/hr. to $275/hr.
Annual Cost to Federal Government:
$22,053
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Bertinia Smith-Butler 301 415-7000
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
07/11/2019
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