ARFQ DCR2500000083 - Exhibit C - NRC Form 5.pdf

This is an NRC Form 5 exhibit document related to a contract opportunity with the Department of Conservation and Recreation (DCR), identified as ARFQ DCR2500000083. The form serves as a template for recording occupational radiation exposure data and is designed to capture employee information including name, identification number, date of birth, and licensee details. The document includes multiple rows for documenting radionuclide exposure incidents, with fields for radionuclide type, classification, mode of exposure, and intake measurements in Curies (Ci). The form structure accommodates up to twelve separate exposure incidents or records per individual, with designated sections for comments, licensee signature, and date of preparation.

The form functions as a standardized reporting mechanism for organizations holding Nuclear Regulatory Commission (NRC) licenses and dealing with radioactive materials. It requires documentation of specific exposure parameters and facilitates regulatory compliance and occupational health tracking. The exhibit appears to be a blank template form rather than a completed submission, establishing the data collection framework required for radiation protection programs under NRC oversight. No specific pricing terms, set-asides, funding sources, or contract performance dates are indicated within this exhibit document, as it serves primarily as a regulatory reporting tool integrated into the broader contract opportunity.