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NRC FORM 4 U.S. NUCLEAR REGULATORY COMMISSION 

(04-01-2024) 

10 CFR PART 20 

CUMULATIVE OCCUPATIONAL DOSE HISTORY

APPROVED BY OMB NO. 3150-0005 EXPIRES: 04/30/2024 

Estimated burden per response to comply with this mandatory collection request: 15 minutes. This information is required 

to record an individual’s lifetime occupational exposure to radiation to ensure that the cumulative exposure to radiation 

does not exceed regulatory limits. Send comments regarding burden estimate to the FOIA, Library, and Information 

Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by email to 

Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, 

(3150-0005), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503. 

The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the 

document requesting or requiring the collection displays a currently valid OMB control number.

1. NAME (LAST, FIRST, MIDDLE INITIAL) 2. IDENTIFICATION NUMBER* 3. ID TYPE 4. SEX MALE

FEMALE

5. DATE OF BIRTH 

 (MM/DD/YYYY) 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY) 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD

ESTIMATE

NO RECORD

10. ROUTINE

PSE

11a. EDEX 11b. DDE 12. LDE 13. SDE,WB 14. SDE,ME 15. CEDE 16. CDE 17. TEDE 18. TODE 

19. SIGNATURE OF MONITORED INDIVIDUAL 20. DATE SIGNED 21. CERTIFYING ORGANIZATION 22. SIGNATURE OF DESIGNEE 23. DATE SIGNED 

NRC FORM 4 (04-01-2024) 

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*Note: Social Security Numbers must not be visible on the outside of any package sent by mail.
INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE 

COMPLETION OF NRC FORM 4 

(All doses should be stated in rems)

PRIVACY ACT STATEMENT 

NRC FORM 4 

CUMULATIVE OCCUPATIONAL DOSE HISTORY

1. Type or print the full name of the monitored individual in 

 the order of last name (include “Jr,” “Sr,” “III,” etc.), first 

 name, middle initial (if applicable).

2. Enter the individual’s identification number, do not include 

 punctuation. This number should be the 9-digit social 

 security number if at all possible. If the individual has no 

 social security number, enter the number from another 

 official identification such as a passport or work permit. 

3. Enter the code for the type of identification used as shown 

 below:

CODE ID TYPE 

SSN U.S. Social Security Number 

PPN 

CSI Canadian Social Insurance Number 

WPN 

PADS Identification Number 

Other 

4. Check the box that denotes the sex of the individual being 

 monitored. 

5. Enter the date of birth of the individual being 

 monitored in the format (MM/DD/YYYY). 

6. Enter the monitoring period for which this report is filed. 

 The format should be (MM/DD/YYYY) - (MM/DD/YYYY). 

7. Enter the name of the licensee or facility not licensed by 

 NRC that provided monitoring. 

8. Enter the NRC license number or numbers. 

9. Place an “X” in Record, Estimate, or No Record. Choose 

 “Record” if the dose data listed represent a final 

 determination of the dose received to the best of the 

 licensee’s knowledge. Choose “Estimate” only if the listed 

 dose data are preliminary and will be superseded by a 

 final determination resulting in a subsequent report. An 

 example of such an instance would be dose data based 

 on self-reading dosimeter results and the licensee intends 

 to assign the record dose on the basis of TLD results that 

 are not yet available. If the individual or an organization 

 has indicated that the individual was monitored, but the 

 monitoring records could not be obtained, enter “No 

 Record” for this monitoring period. The individual would 

 not be available for a PSE. For monitoring periods during 

 the current year where records are not available, reduce 

 the individual’s allowable dose by 1.25 rems for each 

 quarter for which records were unavailable as required by 

 10 CFR 20.2104(e)(1).

10. Place an “X” in either Routine or PSE. Choose “Routine” 

 if the data represent the results of monitoring for routine 

 exposures. Choose “PSE” if the listed dose data 

 represents the results of monitoring of planned special 

 exposures received during the monitoring period.

11A. EDEX – Enter the EDEX for the entire monitoring period 

 (e.g., year). EDEX is the sum of the EDEX component 

 determined using NRC-approved special dosimetry methods 

 (see RG 8.40) and the EDEX component estimated by the 

 DDE for those time periods when not using NRC-approved 

 special dosimetry methods. 

11B. DDE – Enter the DDE measured at the highest point on the 

 whole body for the entire monitoring period (e.g.,year – 

 including those time periods when EDEX was being 

 determined using NRC-approved special dosimetry 

 methods).

12. Enter the eye dose equivalent (LDE) recorded for the lens of 

 the eye. 

13. Enter the shallow dose equivalent recorded for the skin 

 of the whole body (SDE,WB). 

14. Enter the shallow dose equivalent recorded for the skin of the 

 extremity receiving the maximum dose (SDE,ME). 

15. Enter the committed effective dose equivalent (CEDE).

16. Enter the committed dose equivalent (CDE) recorded for the 

 maximally exposed organ. 

17. Enter the total effective dose equivalent (TEDE). The TEDE 

 is the sum of items 11a and 15. 

18. Enter the total organ dose equivalent (TODE) for the 

 maximally exposed organ. The TODE is the sum of items 

 11b and 16. 

19. Signature of the monitored individual. The signature of the 

 monitored individual on this form indicates that the 

 information contained on the form is complete and correct to 

 the best of his or her knowledge. 

20. Enter the date this form was signed by the monitored 

 individual.

21. [OPTIONAL] Enter the name of the licensee or facility not 

 licensed by NRC, providing monitoring for exposure to 

 radiation (such as a DOE facility) or the employer if the 

 individual is not employed by the licensee and the employer 

 chooses to maintain exposure records for its employees. 

22. [OPTIONAL] Signature of the person designated to represent 

 the licensee or employer entered in item 21. The licensee or 

 employer who chooses to countersign the form should have 

 on file documentation of all the information on the NRC 

 Form 4 being signed. 

23. [OPTIONAL] Enter the date this form was signed by the 

 designated representative. 

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 4. This 

information is maintained in a system of records designated as NRC-27 and described at 84 

Federal Register 71558 (December 27, 2019), or the most recent Federal Register

publication of the NRC's Systems of Records Notices that is located in NRC's Agencywide 

Documents Access and Management System (ADAMS).

1. AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2051, 2073, 2093, 2095, 2111, 

2133, 2134, and 2201(o); 10 CFR Parts 20 and 34; Executive Order (E.O.) 9397, as 

amended by E.O. 13478; E.O. 12196, as amended; E.O. 13708.

2. PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of the 

risk of exposures to radiation and radioactive material associated with licensed activities 

and in exercising its statutory responsibility to monitor and regulate the safety and health 

practices of its licensees. The data permits a meaningful comparison of both current and 

long-term exposure experience among types of licensees and among licensees within each 

type. Data on your exposure to radiation is available to you upon your request.

3. ROUTINE USE(S): In addition to the disclosures permitted under subsection (b) of the 

Privacy Act, information may be used to provide data to other Federal and State agencies 

involved in monitoring and/or evaluating radiation exposure received by individuals 

monitored for radiation exposure while employed by or visiting or temporarily assigned to 

certain NRC licensed facilities; and to return data provided by licensee upon request. 

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; in the course of an administrative or judicial proceeding; 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; 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; to NRC-paid experts, consultants, and others under contract with the NRC, on 

a need-to-know basis; or to appropriate persons and entities for purposes of response and 

remedial efforts in the event of a suspected or confirmed breach of data from this system of 

records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON 

INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the 

requested information, including the Social Security number (SSN) in block #2. The SSN is 

used to assure that NRC has an accurate and unique identifier not subject to the 

coincidence of similar names or birth dates among the large number of persons on who data 

is maintained and to assure that there are no missed doses or monitoring periods and an 

individual gets a complete dose history when requested. The licensee must complete NRC 

Form 5 on each individual for whom personnel monitoring is required under 10 CFR 

20.1502. In addition, licensees must submit this information to NRC in accordance with the 

requirement under 10 CFR 20.2206. Failure to do so may subject the licensee to 

enforcement action in accordance with 10 CFR 20.2401.

5. SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection 

Branch, Division of Systems Analysis, Office of Nuclear Regulatory Research, U.S. Nuclear 

Regulatory Commission, Washington, DC 20555-0001.

Passport Number

Work Permit Number 

PADS 

OTH

 Note: If EDEX has been determined by measuring the DDE 

 (at the highest exposed part of the whole body – see 10 CFR 

 20.1201(c)) for the entire monitoring period, then box 11a 

 and 11b will have the same value.