31310019R0054_Attachment_No._6_NRC_445.pdf

NRC FORM 445

(05-2018)

U.S. NUCLEAR REGULATORY COMMISSION

Estimated burden per response to comply with this voluntary collection request: 2 hours. NRC uses this form to authorize foreign travel for non-Federal personnel in the course of conducting business for the NRC. Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0193), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection .

APPROVED BY OMB: NO. 3150-0193 EXPIRES: 05/31/2021

NRC MD 14.1

REQUEST FOR APPROVAL OF

OFFICIAL FOREIGN TRAVEL

Page 1 of 3NRC FORM 445 (05-2018)

A. TRAVELER INFORMATION (To be completed by traveler) Name of Traveler Position Title

Country of Travel

Departure Date Return Date

Is your official passport valid?

Yes No Does your trip require a visa?

Yes No

I will adhere to all ethical codes of conduct while on travel. I understand that I must contact the NRC Health Center (301) 415-8400 to consult on possible medical issues and precautions, including recommended inoculations or other medications and educational materials.

Signature of Traveler Signature Date

Purpose of Travel (Please provide a brief description of the purpose for your travel. Please spell out all acronyms.)

List of Persons with whom Travel has been coordinated (Name and Agency)

NAME

(i.e., Supervisor, OIP Desk Officer, other travelers) AGENCY/OFFICE

B. REVIEW AND APPROVAL

Signature of Office Director/Regional Administrator Signature Date

Signature of Deputy Director, OIP (if required) Signature Date

Signature of Chairman (if required) Signature Date

U.S. NUCLEAR REGULATORY COMMISSION

NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)

NRC FORM 445 (05-2018) Page 2 of 3

C. TRAVEL ITINERARY

Date Location (City, Country)

Contact on Site (Name, telephone number, and e-mail address) Activity "X" If

Classified

D. FUNDING

Source of Funding Job Code

(05-2018)

NRC MD 14.1

U.S. NUCLEAR REGULATORY COMMISSION

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)

PRIVACY ACT STATEMENT

NRC FORM 445

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 445. This information is maintained in a system of records designated as NRC-20 and described at 81 Federal Register 81334-81335 (November 17, 2016), or the most recent Federal Register publication of the NRC's “Republication of Systems of Records Notices” located in the NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter 61; 41 CFR 102-118;

Executive Order (E.O.) 9397, as amended by E.O. 13478.

2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.

3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may disclose information from this system of records to the U.S. Treasury for payment; the Department of State or an embassy for passports or visas; the General Services Administration and the Office of Management and Budget for required periodic reporting; the charge card issuing bank; the Department of Interior, National Business Center, for collecting severe travel card delinquencies by employee salary offset; and to a consumer reporting agency to obtain credit reports. The information may also be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis;

and to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT

PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided approval for foreign travel may be denied.

5. SYSTEM MANAGER AND ADDRESS: Chief, International Operations Branch, Office of International Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

U.S. NUCLEAR REGULATORY COMMISSION

Estimated burden per response to comply with this voluntary collection request: 2 hours. NRC uses this form to authorize foreign travel for non-Federal personnel in the course of conducting business for the NRC. Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0193), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection .

APPROVED BY OMB: NO. 3150-0193

EXPIRES: 05/31/2021

G:\FORMS\LOGOS\NRCSEALblack (4).JPG

NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL

NRC FORM 445 (05-2018)

NRC FORM 445

(05-2018)

U.S. NUCLEAR REGULATORY COMMISSION

NRC MD 14.1

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued)

NRC FORM 445 (05-2018)

A. TRAVELER INFORMATION (To be completed by traveler) Is your official passport valid?

Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Does your trip require a visa?

Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials I will adhere to all ethical codes of conduct while on travel. I understand that I must contact the NRC Health Center (301) 415-8400 to consult on possible medical issues and precautions, including recommended inoculations or other medications and educational materials.

Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Signature of Traveler List of Persons with whom Travel has been coordinated (Name and Agency)

NAME

(i.e., Supervisor, OIP Desk Officer, other travelers)

AGENCY/OFFICE

B. REVIEW AND APPROVAL

Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Signature of Office Director/Regional Administrator Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Signature of Deputy Director, OIP (if required) Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Director, OPA, Director DFS, (only for requests for visitors of the Media and sponsored by OPA): Approvers Initials Signature of Chairman (if required)

C. TRAVEL ITINERARY

Date Location (City, Country) Contact on Site (Name, telephone number, and e-mail address) Activity "X" If Classified

D. FUNDING

NRC FORM 445

(05-2018)

NRC MD 14.1

U.S. NUCLEAR REGULATORY COMMISSION

REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL (Continued) PRIVACY ACT STATEMENT NRC FORM 445 REQUEST FOR APPROVAL OF OFFICIAL FOREIGN TRAVEL Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-570), the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 445. This information is maintained in a system of records designated as NRC-20 and described at 81 Federal Register 81334-81335 (November 17, 2016), or the most recent Federal Register publication of the NRC's “Republication of Systems of Records Notices” located in the NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 5 U.S.C. Part III, Subpart D, Chapter 57; 31 U.S.C. 716; 41 U.S.C. Subtitle II, Chapter 61; 41 CFR 102-118; Executive Order (E.O.) 9397, as amended by E.O. 13478.

2. PRINCIPAL PURPOSE(S): To secure the required NRC approval for official foreign travel.

3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the Privacy Act, the NRC may disclose information from this system of records to the U.S. Treasury for payment; the Department of State or an embassy for passports or visas; the General Services Administration and the Office of Management and Budget for required periodic reporting; the charge card issuing bank; the Department of Interior, National Business Center, for collecting severe travel card delinquencies by employee salary offset; and to a consumer reporting agency to obtain credit reports. The information may also be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; and to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT

PROVIDING INFORMATION: Disclosure is voluntary, however, if the requested information is not provided approval for foreign travel may be denied.

5. SYSTEM MANAGER AND ADDRESS: Chief, International Operations Branch, Office of International Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

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