Information Collection

NRC Form 176, Security Acknowledgment and Termination Statement.

IC 236852 under ICR 201907-3150-004 · OMB 3150-0239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0239 can be found here:

Documents and Forms

Document Name Document Type
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction
NRC Form 176 SECURITY ACKNOWLEDGMENT NRC 176 (OMB Copy) (06-26-2019) new (003).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NRC Form 176, Security Acknowledgment and Termination Statement.	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 10 CFR 9

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 176	SECURITY ACKNOWLEDGMENT	NRC 176 (OMB Copy) (06-26-2019) new (003).pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: NRC-39, Personnel Security Files and Associated Records-NRC	FR Citation: 77 FR 22561

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	80	80
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.