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Federal forms, ICRs, and supporting documents

Information Collection Request

NRC Form 176 - Security Acknowledgment and Termination Statement

ICR 202208-3150-007 · OMB 3150-0239 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction Modified Repair queued
2022-17811.pdf Supplementary Document Uploaded 2022-08-19 Repair queued
30-day Supporting Statement ML22158A099 (1).pdf Supporting Statement A Uploaded 2022-08-18 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
236852 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction Modified
ICR Details
3150-0239 202208-3150-007
Received in OIRA 201907-3150-004
NRC
NRC Form 176 - Security Acknowledgment and Termination Statement
Extension without change of a currently approved collection   No
Regular 08/19/2022
  Requested Previously Approved
36 Months From Approved 10/31/2022
400 400
80 80
0 0
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.
EO: EO 12958 Name/Subject of EO: Section 4.3
  
None
Not associated with rulemaking
  87 FR 19982 04/06/2022
87 FR 51161 08/19/2022
No
1
IC Title Form No. Form Name
NRC Form 176, Security Acknowledgment and Termination Statement. NRC Form 176 Security Acknowledgment and Termination Statement
  Total Request 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 400 400 0 0 0 0
Annual Time Burden (Hours) 80 80 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$23,040
No
    No
    No
No
No
No
No
Karen Skidmore 301 415-7000
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/19/2022