NRC Form 4 – Cumulative Occupational Dose History

Form Number: NRC Form 4 Form Title: Cumulative Occupational Dose History Current Edition: 11-2020 Authority Directive or Regulation: 10 CFR Part 20 Form Status: Approved by OMB: 3150-0005, Expires: 11/30/2023 Special Instructions:

Instructions and additional information pertinent to the completion of this form are on Page 2 of the form.

For Questions:

E-mail: Minh-Thuy.Nguyen@nrc.gov RES/DSA/RPB Nuclear Engineer NSPDP

Telephone Number: (301) 415-5163

Page Last Reviewed/Updated Tuesday, December 01, 2020