NRC Form 176 - Security Acknowledgment and Termination Statement

Forms and Documents

Document Name	Status
Form NRC Form 176 NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction	Modified
OMB 3150-0239, Final Supporting Statement for NRC Form 176, Security Acknowledgement and Termination Statement.docx Supporting Statement A	2025-11-26
2025-21311.pdf Supplementary Document	2025-11-26

IC Document Collections

IC ID	Document Title	Status
236852	NRC Form 176, Security Acknowledgment and Termination Statement. Form and Instruction	Modified

ICR Details

OMB Control No: 3150-0239	ICR Reference No: 202511-3150-004
Status: Received in OIRA	Previous ICR Reference No: 202208-3150-007
Agency/Subagency: NRC	Agency Tracking No:
Title: NRC Form 176 - Security Acknowledgment and Termination Statement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/26/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2025
Responses	1,000	400
Time Burden (Hours)	200	80
Cost Burden (Dollars)	0	0

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Abstract: The NRC Form 176, “Security Acknowledgment and Termination Statement” is completed by employees, licensees and contractors in connection with the termination of their access authorization/security clearance granted by the NRC and to acknowledgment and accept their continuing security responsibility.

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Authorizing Statute(s): EO: EO 12958 Name/Subject of EO: Section 4.3
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 24165	06/06/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 54403	11/26/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NRC Form 176, Security Acknowledgment and Termination Statement.	NRC Form 176	Security Acknowledgement and Termination Statement

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000	400	0	0	600	0
Annual Time Burden (Hours)	200	80	0	0	120	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: NRC Form 176 has added “Controlled Unclassified Information” to the form which increases the number of future users that will need to sign the form before gaining access to sensitive non-classified information. The NRC modified the form to include a print name field in addition to the signature field for clarity. There is no change in the burden required to complete the form. In response to a comment received from the 60-day comment period, the NRC Form 176A #10 was changed to match the language of the MD 12.3. The responses increased from 400 responses to 1,000 responses (an increase of 600 responses) and the total burden has increased from 80 hours to 200 hours (an increase of 120 hours). The cost has increased due to a change in the fee rate from $288 per hour to $317 per hour.

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Annual Cost to Federal Government: $63,453

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/26/2025

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