Information Collection

NRC Form 4 (3150-0005 NRC Licensees RK Burden)

IC 181278 under ICR 200707-3150-007 · OMB 3150-0203.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0203 can be found here:

Documents and Forms

Document Name Document Type
Form NRC Form 4 NRC Form 4 (3150-0005 NRC Licensees RK Burden) Form and Instruction
NRC Form 4 Cumulative Occupational Dose History nrc4.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NRC Form 4 (3150-0005 NRC Licensees RK Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 4	Cumulative Occupational Dose History	nrc4.pdf		No		Fillable Printable

Line of Business: Energy

Subfunction: Energy Resource Management

Privacy Act System of Records
Title: NRC-27	FR Citation: 69 FR 57601

Number of Respondents: 6	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.