ARFQ DCR2500000083 - Exhibit C - NRC Form 5.pdf

This document is NRC Form 5, an Occupational Dose Record form issued by the U.S. Nuclear Regulatory Commission (NRC) for tracking individual radiation exposure during monitoring periods. The form is designed to record detailed information about radiation doses received by individuals working with nuclear materials, including various types of dose measurements such as effective dose equivalent, deep dose equivalent, lens dose equivalent, and shallow dose equivalents for whole body and extremities.

The form requires tracking of specific radionuclides, their classification, mode of intake, and intake amounts in μCi. It includes fields for recording different types of dose measurements in rem units, including committed effective dose equivalent (CEDE) and total organ dose equivalent (TODE). The form must be signed by a licensee representative and is subject to OMB approval (No. 3150-0006, expires 11/30/2027). The estimated burden for completing this mandatory collection is 20 minutes per response, and the form serves as an official record for ensuring regulatory compliance with radiation exposure limits.