ARFQ DCR2500000083 - Exhibit C - NRC Form 5.pdf

The document is a U.S. Nuclear Regulatory Commission (NRC) Occupational Dose Record Form (NRC Form 5), which is a standardized template for tracking and reporting radiation exposure for workers in nuclear-related industries. The form is designed to record individual occupational radiation exposure details, including intake of radionuclides, various dose equivalent measurements, and monitoring period information. This form is part of the NRC's regulatory compliance requirements for tracking and managing radiation exposure for workers, with an OMB approval number 3150-0006 and an expiration date of 11/30/2027.

The form provides comprehensive fields for documenting radiation exposure data, including sections for personal identification (without displaying social security numbers), monitoring period, licensee information, radionuclide intakes, and dose measurements across multiple categories such as effective dose equivalent, deep dose equivalent, lens dose equivalent, and committed dose equivalent. The form includes privacy act statements explaining the legal authority for collecting this information (5 U.S.C. 552a), the principal purposes of data collection, routine uses, and disclosure requirements. It is intended to help the NRC evaluate radiation exposure risks, monitor worker safety, and maintain a systematic record of occupational radiation exposure for licensed facilities and workers.