Brc Form 202 3 PDF Details

The BRC Form 202-3, also known as the Supplement to the Facility Security Plan (SFP), is a document that provides additional security information for facilities that handle or store controlled unclassified information. The form must be completed and submitted to the Department of Homeland Security's (DHS) National Protection and Programs Directorate (NPPD). In this blog post, we will discuss what the BRC Form 202-3 is, who needs to complete it, and what information needs to be included. Stay tuned for our next post, which will provide a step-by-step guide on how to complete the form.

QuestionAnswer
Form NameBrc Form 202 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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PAGE ______ OF ______

BRC Form 202-3

 

 

Texas Department of Health/Bureau of Radiation Control

 

 

 

 

(October 2000)

 

 

 

 

 

 

 

 

 

OCCUPATIONAL EXPOSURE RECORD

 

 

 

 

 

 

FOR A MONITORING PERIOD

 

 

 

 

 

1. NAME (LAST, FIRST, MIDDLE INITIAL)

 

2. IDENTIFICATION NUMBER

3. ID TYPE

4. SEX

 

 

5. DATE OF BIRTH

 

 

 

 

 

MALE

FEMALE

 

6. MONITORING PERIOD

 

7. LICENSEE OR REGISTRANT NAME

8. LICENSE OR REGISTRATION

9A.

 

9B.

 

 

 

 

NUMBER(S)

 

RECORD

ROUTINE

 

 

 

 

 

 

 

 

 

 

 

 

ESTIMATE

PSE

 

INTAKES

 

 

DOSES (IN REM)

 

 

 

 

 

 

 

 

 

10A. RADIONUCLIDE

10B. CLASS

10C. MODE

10D. INTAKE IN FCi

 

 

 

 

 

 

 

 

DEEP DOSE EQUIVALENT

 

 

(DDE)

11.

 

 

 

 

 

 

 

 

 

EYE DOSE EQUIVALENT TO THE LENS OF THE EYE

 

(LDE)

12.

 

 

 

 

 

 

 

 

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,

 

 

16.

 

 

 

MAXIMALLY EXPOSED ORGAN

 

 

(CDE)

 

 

 

 

TOTAL EFFECTIVE DOSE EQUIVALENT

 

 

17.

 

 

 

 

 

(BLOCKS 11+15)

(TEDE)

 

 

 

 

TOTAL ORGAN DOSE EQUIVALENT,

 

 

18.

 

 

 

MAX ORGAN

(BLOCKS 11+16)

(TODE)

 

 

 

 

19. COMMENTS

 

 

 

 

20. SIGNATURE -- LICENSEE OR REGISTRANT

 

 

 

 

 

 

21. DATE PREPARED

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE

COMPLETION OF BRC FORM 202-3

(ALL DOSES SHOULD BE STATED IN REMS)

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:

CODE

ID TYPE

 

SSN

U.S. Social Security Number

PPN

Passport Number

CSI

Canadian Social Insurance Number

WPN

Work Permit Number

IND

INDEX Identification Number

OTH

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/YY.

6.Enter the monitoring period for which this report is filed. The format should be MM/DD/YY - MM/DD/YY.

7.Enter the name of the licensee or registrant.

8.Enter the Agency license or registration number or numbers.

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 or registrant'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.

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 or registrant should sum them and report the total of all PSEs.

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.

10B. Enter the lung clearance class as listed in Appendix B to Part D (D, W, Y, V, or O for other) for all intakes by inhalation.

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 FCi.

11.Enter the deep dose equivalent (DDE) to the whole body.

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) or "NR" for "Not Required" or "NC" for "Not Calculated".

16.Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ or "NR" for "Not Required" or "NC" for "Not Calculated".

17.Enter the total effective dose equivalent (TEDE). The TEDE is the sum of items 11 and 15.

18.Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of items 11 and 16.

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 overexposed report has been sent to the Agency in reference to the exposure report.

20.Signature of the person designated to represent the licensee or registrant.

21.Enter the date this form was prepared.