Office of Health, Safety and Security Collection Package
Human Reliability Program
OMB 1910-5122
Description of Collections

1. Human Reliability Program Certification (DOE F 470.3). Under the Department of Energy Human Reliability Program (HRP), individuals who are applicants for or incumbents in designated positions must be evaluated to ensure that they meet the requirements for certification in the program. This form documents that each part of the evaluation has been completed and records the determination by the HRP Certifying Official. The collection and documentation of this information is required by the HRP regulation found in the Code of Federal Regulations at 10 CFR 712. Form may be viewed at: http://energy.gov/cio/downloads/doe-f-4703

2. Acknowledgement and Agreement to Participate in the Human Reliability Program (DOE F 470.4). This form documents an individual's consent to participate in the Human Reliability Program (HRP) and his or her acknowledgement that he or she is fully aware of all of the requirements for participation in the program, including medical and psychological assessments and drug and alcohol testing. The individual's signature on this form is required by 10 CFR 712.11(a)(3), General requirements for HRP certification. Form may be viewed at: http://energy.gov/cio/downloads/doe-f-4704

3. Authorization and Consent to Release Human Reliability Program (HRP) Records in Connection with HRP (DOE F 470.5). The individual's signature on this form documents his or her authorization to release medical and non-medical records developed during the HRP certification process relevant to his or her eligibility to occupy an HPR position. The form authorizes the release of these records to those contractor management and DOE officials who have a legitimate need for the information in the performance of their duties and responsibilities under the HRP process. The individual's signature on this form is required as a condition of certification in the HRP in accordance with 10 CFR 712.11(a)(3). Form may be viewed at: http://energy.gov/cio/downloads/doe-f-4705

being provided with full information on the requirements of the HRP, he or she declines to participate in the program and understands that he or she will not be assigned to an HRP position. Form may be viewed at: http://energy.gov/cio/downloads/doe-f-4706

5. Human Reliability Program (HRP) Alcohol Testing Form (DOE F 470.7). This form documents breath alcohol test procedures conducted under the HRP, as well as the individual's signature to acknowledge that the identifying information entered on the form is correct. If the individual is found to have a blood alcohol level greater than the limit specified under the HRP, the individual also signs understands that he or she will be sent home and will not be allowed to return to HRP duties for 24 hours. The collection and documentation of this information is authorized by 10 CFR 712.15(c), Alcohol testing. Form may be viewed at: http://energy.gov/cio/downloads/doe-f-4707