Form NRC Form 277 NRC Form 277 Request for Visit or Access Authorization

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the
following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC)
on NRC Form 277. This information is maintained in a system of records designated as NRC-39 and described at 71
Federal Register 59642 (October 10, 2006), or the most recent Federal Register publication of the NRC's "Republication
of Systems of Records Notices" that is located in the NRC's Agencywide Documents Access and Management System
(ADAMS).
1. AUTHORITY: 40 U.S.C. 318; 42 U.S.C. 2165 and 2201(I); Executive Order (E.O.) 9397; E.O. 10450, as amended by
E.O.s 10491, 10531, 10548, 10550, 11605, 11785, 12107; E.O. 12958, as amended by E.O. 13292; E.O. 12968; E.O.
10865, as amended by E.O.s 10909, 11382, modified by E.O. 12038; 10 CFR Parts 10, 11, 25, 73; Pub. L. 99-399
(100 Stat. 876); OMB Circular No. A-130, Revised; 5 CFR Parts 731 and 732 and authorities cited therein; Pub. L.
99-500 (100 Stat. 1783-335).
2. PRINCIPAL PURPOSE(S): To verify an individual's security clearance and authorization for access for a classified
visit.
3. ROUTINE USE(S): Information may be used on a need-to-know basis by NRC officials, Hearing Examiners,
Personnel Security Review Panel members, OPM, CIA and other Federal agencies to determine/certify clearance or
access authorization; to determine eligibility for access to NRC buildings or access to Federal automated information
systems or data; to maintain the NRC personnel security program; and to provide licensees criminal history
information needed for their unescorted access or access to safeguards information determinations. Information may
be disclosed in accordance with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses,
including to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or
potential violation of law and in the course of an administrative or judicial proceeding. In addition, this information may
be transferred to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an
NRC decision about you or to the extent relevant and necessary for that agency's decision about you. Information may
also be disclosed, in the course of discovery under a protective order issued by a court of competent jurisdiction, and
in presenting evidence, to a Congressional office to respond to their inquiry made at your request, or to NRC-paid
experts, consultants, and others under contract with the NRC, on a need-to-know basis.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT
PROVIDING INFORMATION: It is voluntary that you furnish the requested information, however, failure to provide the
requested information may result in the denial of entrance and/or access to the agency or facility and the information
to which access is requested. Failure to provide the social security number may delay processing. The use of the
social security number is necessary to verify clearance information because of the large number of individuals who
have identical names and birth dates, and whose identities can only be distinguished by the social security number.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001.

EXPIRES: MM/DD/YYYY

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-XXXX

NRC FORM 277
(M-YYYY)
NRC MD 12.3

REQUEST FOR VISIT
(Not to be used for temporary or permanent personnel assignments)

Estimated burden per response to comply with this mandatory information collection request: 10
minutes. This submittal is used to validate the level of access authorized during an official visit. Send
comments regarding burden estimate to the Records and FOIA/Privacy Services Branch (T-5 F53), U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to
infocollects.resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs,
NEOB-10202, (3150-XXXX), Office of Management and Budget, Washington, DC 20503. If a means
used to impose an information collection does not display a currently valid OMB control number, the
NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

PART A
Date

To

Personnel Security Branch, DFS/ADM
Telephone Number

From (Requesting Office -- Branch Chief or Above)

CERTIFY PURPOSE/NEED FOR VISIT REQUEST

SIGNATURE OF REQUESTING NRC OFFICIAL

TITLE

Date

INCLUSIVE DATES
From
To

NAME OF FACILITY(IES) TO BE VISITED

Purpose of visit:
Visit Point of contact:

Telephone

Facsimile

Security Point of contact:

Telephone

Facsimile

Program/Level of access requested:

Prior arrangements:

have not been made or

have been made as follows:

PART B
It is requested that the following person(s) be granted visit/access approval:
LAST NAME, FIRST NAME,
MIDDLE INITIAL

SOCIAL SECURITY
NUMBER

U.S.
CITIZEN

DATE
OF
BIRTH

POB STATE or
COUNTRY

DATE/
DATE/
TYPE OF
TYPE OF
CLEARANCE INVESTIGATION

YES
YES
YES
YES
YES
Name/Title of NRC Security Official

Date

Signature

PART C
Remarks:

NRC FORM 277 (M-YYYY)