Attachment_S-5_-_NN-1421.doc

NN 1421 (Rev 16)

NNPP Visit (106.6 Not Trained) Dosimetry Authorization Request (V-DAR) Page 1of 2 Section 1 Personal Identification and Employment Information

Name: (Last, First, MI)

ID#:

PERNRSSN

Parent Organization Name and Address:

Visitor’s Home Address:

Expected Arrival Date:

FORMTEXT

Expected Departure Date:

NNS Visitor’s Representative Approval:

Printed Name:

Signature:

Phone:

Date:

Section 2 Occupational Dose History - All dose equivalents in mrem; enter “N/M” if not monitored ,”N/R” if not required

Current Year Dose

Section 3 Reporting Information

Send Annual Form 5 to Individual Do not send Annual Form 5 to Individual (Parent Organization will send annual dose information)

Report Dose to NAVMED ( Parent Organization Dose not report to NAVMED) Do not report Dose to NAVMED (Parent Organization reports to NAVMED)

Section 4 Control Level and Training Information

Control Level 50 mrem/year

· “I have read and understand the NNS Visitor Training pamphlet and “The Radiation in the Shipyard” pamphlet.

Control Level 100 mrem/year

· “I have read and understand the NNS Visitor Training pamphlet and “The Radiation in the Shipyard pamphlet”.

· “I have read NAVSEA 380-0288 Appendix M”.

· “The recommendations of the National Council on Radiation Protections and Measurements to limit radiation exposure to the unborn child to the very lowest practical level, not to exceed 0.5 rem during the entire pregnancy have been explained to me.”

Individual’s Signature: Date:

Section 5 Medical Qualification Information

Radiation Physical Not Required, NAVSEA 389-0288 Article 240.3 requires individual to sign the following statement:

“I know of no medical condition that would prevent my receiving radiation exposure within prescribed Federal Standards.”

Individual’s Signature: Date:

Section 6 Individual Acknowledgement of Privacy Information

The social security number (SSN) is used to assure that regulators, both Federal and Navy, have an accurate identifier not subject to the coincidence of similar names or birth dates among the large number of persons for whom this data is maintained. It was voluntary that you furnish the requested information, including SSN. Information on this form is communicated to and used by regulators in exercising their responsibility to monitor and regulate safety and health practices. The information may also be disclosed to other appropriate government agencies in the event the information indicates violation, or potential violation, of law, or in the course of administrative/judicial proceedings.

Individual’s Signature: Date:

Section 7 Dosimetry Section Use Only

NNPP (106.6 Not Trained) Visitor Dosimetry Authorization Request (V-DAR) Page 2 of 2

Section 8 Authorization Information for Untrained Visitors -To be completed by requesting Department/Organization

Name: (Last, First, MI)

ID#:

PERNR Last 4 of SSN

Requesting Depart/Org.

Requesting Department/ Organization Point of Contact and Person who is Responsible for Ensuring that the Visitor has an Appropriately Trained Escort:

Print Name:

Phone:

Signature:

Date:

Is visitors Parent Organization part of the NNPP? If “No” Answer questions 1. Through 3. Yes

1. Will the visit require the individual to handle radioactive material, access a Controlled Surface Contamination Area, a Radiological Controlled Area or a High Radiation Area?

Yes, prior approval must be obtained from NAVSEA 08/ attach documentation. No

2. Will visitor be required to perform highly radioactive work, e.g. decontamination of components, or inspection and repair of contaminated internals of a large primary component?

Yes, Internal monitoring required prior to authorization and prior to departure, attach Internal Monitoring Reports. No

3. Does the expertise to perform this work exist anywhere else within NNS or the NNPP?

Yes, explain why this particular visitor’s services are needed:

No

Purpose of Visit:

Work –Describe nature of work: Observation Only

List Locations/Areas to be visited: (Identify the hull/building number, spaces etc…)

Radioactive Material Handing:

Will the visitor directly handle any radioactive material? If Yes, list/describe material(s) to be handled and associated radiation levels : No

Radiological Areas:

Check all types of radiological areas the visitor will need to enter and list the associated radiation level where applicable:

Radiologically Controlled Area (_____mrem/hr) Radioactive Material Storage Area Radiation Area (_____mrem/hr) Fixed Radioactive Contamination Area Controlled Surface Contamination Area

Area Boundary Reduction:

Has RadCon Monitoring evaluated radiological area(s) to determine potential for radiation boundary reduction?

N/A Sea trials and general tour/observation of multiple of areas Yes, Name of Radcon Supervisor contacted;

Phone:

Section 9 Dosimetry Use Only, Training Documentation and Approvals

NAVSEA Article 106.6.A.(2) Checklist of 107 Training Qualification Items

Indicate if training is required for an article by checking no yes or

Approvals:

Visitor’s Parent Organization is in the NNPP, Dosimetry Supervisor Approval Required:

Printed Name: Signature: Date:

Visitor’s Parent Organization is Non-NNPP, Manager of Radiation Health and Technical Services Approval Required:

Printed Name: Signature: Date:

QS File (4.13)12

HUNTINGTON INGALLS INDUSTRIES PRIVATE/PROPRIETARY LEVEL 1