9A. 9B.

OCCUPATIONAL DOSE RECORD 

FOR A MONITORING PERIOD

NRC FORM 5

(04-01-2024)

10 CFR PART 20

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0006 EXPIRES: 04/30/2024

Estimated burden per response to comply with this mandatory collection request: 20 minutes. This information is 

used to ensure that doses to individual do not exceed regulatory limits. This information is required to record/

annually report individual occupational exposure to radiation to ensure that the exposure 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, (3150-0006), 

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.

PAGE OF

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(S) RECORD ROUTINE

PSE

20. SIGNATURE - LICENSEE 21. DATE PREPARED

DOSES (in rem) INTAKES

10A. RADIONUCLIDE 10B. CLASS 10C. MODE 10D. INTAKE IN μCi 

LENS (EYE) DOSE EQUIVALENT (LDE)

SHALLOW DOSE EQUIVALENT, 

WHOLE BODY (SDE,WB) 13.

SHALLOW DOSE EQUIVALENT, 

MAX EXTREMITY (SDE,ME) 14.

COMMITTED EFFECTIVE 

DOSE EQUIVALENT (CEDE) 15.

COMMITTED DOSE EQUIVALENT, 

MAXIMALLY EXPOSED ORGAN (CDE) 16.

TOTAL EFFECTIVE DOSE EQUIVALENT 

(ADD BLOCKS 11A AND 15) (TEDE) 17.

19. COMMENTS

NRC FORM 5 (04-01-2024)

EFFECTIVE DOSE EQUIVALENT 

(FOR EXTERNAL EXPOSURES) (EDEX) 11A.

- ESTIMATE

DEEP DOSE EQUIVALENT 

(FOR THE ENTIRE MONITORING PERIOD) (DDE) 11B.

12.

TOTAL ORGAN DOSE EQUIVALENT MAX ORGAN 

(ADD BLOCKS 11B AND 16) (TODE) 18.

*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 5 

(All doses should be stated in rems)

PRIVACY ACT STATEMENT 

NRC FORM 5 

OCCUPATIONAL DOSE RECORD FOR A MONITORING PERIOD

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 5. 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.

9A. Place an “X” in Record, or Estimate. 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.

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, 

 including 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:

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.

8. Enter the NRC license number or numbers.

10A. Enter the symbol for each radionuclide that 

 resulted in an internal exposure recorded for 

 the individual, using the format "Xx-###x," for 

 instance Cs-137 or Tc-99m.

10C. Enter the mode of intake. For inhalation, enter 

 "H." For absorption through the skin, enter "B." 

 For oral ingestion, enter "G." For injection, 

 enter "J." 

10D. Enter the intake of each radionuclide in μCi. 

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 lens does 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).

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.

19. COMMENTS: In the space provided, enter 

 additional information that might be needed to 

 determine compliance with limits. An example 

 might be to enter the note that the SDE,ME was 

 the result of exposure from a discrete hot particle. 

 Another possibility would be to indicate that an 

 over exposed report has been sent to NRC in 

 reference to the exposure report. 

20. Signature of the person designated to represent 

 the licensee.

21. Enter the date this form was prepared. 

9B. 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. If more 

than one PSE was received in a single year, the licensee 

should sum them and report the total of all PSEs. 

CODE ID TYPE 

SSN U.S. Social Security Number 

PPN 

CSI Canadian Social Insurance Number 

WPN 

PADS Identification Number 

Other 

Passport Number

Work Permit Number 

PADS 

OTH

10B. Enter the lung clearance class as listed in 

 Appendix B to 10 CFR Part 20.1001-2401 (D, W, 

 Y, V, F, M, S, or O for other) for all intakes by 

 inhalation. 

11A. Enter the effective dose equivalent (EDEX).

14. Enter the shallow dose equivalent recorded for the 

 skin of the extremity receiving the maximum dose 

 (SDE,ME). 

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

 the maximally exposed organ. The TODE is the 

 sum of items 11B and 16. 

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

radiation and radioactive materials 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, this 

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; or 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. 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.