ARFQ DCR2500000066 - Exhibit C - NRC Form 5.pdf

This document is NRC Form 5, an Occupational Dose Record form used by the U.S. Nuclear Regulatory Commission (NRC) for monitoring radiation exposure periods. The form is approved under OMB No. 3150-0006 and expires on 11/30/2027. It is designed to record individual occupational exposure to radiation to ensure compliance with regulatory limits, with an estimated completion time of 20 minutes per response.

The form captures detailed radiation exposure data including effective dose equivalent (EDEX) for external exposures, deep dose equivalent (DDE), lens dose equivalent (LDE), shallow dose equivalents for whole body and extremities, and committed dose equivalents. It requires documentation of radionuclide intakes measured in μCi, along with their classification and mode of intake. The form includes fields for monitoring period dates, licensee information, and individual identification details, with specific instructions prohibiting social security numbers from being visible on package exteriors sent by mail.