ML20006E344

Forwards Revised NRC Forms 396 & 398, Personal Qualification Statement & Certification of Medical Exam by Facility Licensee, Respectively.Applications for Licenses to Be Submitted on Forms by 900201

ML20006E344
Person / Time
Site:	05000097, 05000157
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Streett W CORNELL UNIV., ITHACA, NY
References
NUDOCS 9002220717
Download: ML20006E344 (8)

Text

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k JAN 5 1990 Docket Nos.

50-157 l

50-97 i

Cornell University ATTN:

Dean W. B. Streett College of Engineering 241 Carpenter Hall Ithaca, New York 14853

SUBJECT:

REVISED NRC FORMS 396 AND 398 i

Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualifications Statement - Licensee and revised NRC Form-396 (Enclosure 2),

1 Certification of Medical Examination By Facility Licensee.

All changes to the NRC Form-396 are detailed in Enclosure 3.

Changes to NRC' Form-398 are detailed in Enclosure 4.

All applications for licenses are to be submitted on these revised forms no later than February 1, 1990.

The enclosed applications are for your use. Additional copies can be obtained by contacting Beverly Martin, U.S. Nuclear Regulatory Commission, by telephone (301) 492.-8138 or by writing to her, U.S. Nuclear Regulatory Commission, Information and Records Management Branch, Mail Stop NMBB 7714, Washington, D.C.

20555.

If you have any questions regarding these forms, please contact Richard J.

Conte at (215) 337-5120 or Peter W. Eselgroth at (215) 337-5211.

Sincerely, originni SiSned BY t Robert M. Gallo, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated pf 9

0FFICIAL RECORD COPY 396 & 398 FORMS - 0039.0.0

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A 12/14/89

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L Cornell University 2

.i cc w/ enc 1:

Dr. D. D. Clark, Director, Ward Laboratory of Nuclear Engineering H. Aderhold, Reactor Supervisor, Ward Laboratory Dr. J. Crawford, Director of Environmental Health Dr. William Vernetson, Director of Nuclear Facilities, University of Florida Public Document Roots (PDR) local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

State of New York bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1) l D. Haverkamp, DRP J. Johnson, DRP W. Cook, SRI - Nine Mile Point OL Facility File DRS:RI Gallo/pb 01/02/90, p lb ' [' ) Y3 I

I, 0FFICIAL RECORD COPY 396 & 398 FORMS - 0040.0.0 12/14/89 1

k.

INSTRUCT 60NS FOR ODMPLETING NRC FORM 300 PE RSONAL QUALIFICATION ST AT EMENT-LlCENSEE TO REMAIN VALID, THD FORM MUST NOT BE ALTEIED 4-.

TYPE'CF APPLlCATION 2.s NEW "X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE

. RECElVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE ITEM F4 - THERE IS AN EXCEPT6ON. AL90, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO *NEW,"

2.b thru 2.e-FOR 2.b THRU 2.e, COMPLTTE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION, NOTE: SEE / TEM F4 - THERE 18 AN EXCEPTION.

2.b RENEWAL

• X"lF YOU ARE RENEWING CURRENT LICENSE, 2.s UPGRADE

• X"lF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 2.d MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

2.e REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

2,f WAIVER REQUESTED "X"THLAPPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

2.s DATE l'ASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES).

THis IS NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.

TION SECTION OF THE WRITTEN EXAMINATION WAS PASSFD, IF THE GFESWAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LED TO THE ISSUANCE OF A LICENSE THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

11.

EDUCATION - lNDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION, FOR MAJOR AREA (S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC.

INDICATE THE NUM8ER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDI.

TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 171.

12.

TRAINING - INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI NIB.1/ANS 3.1 THE BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS IF YOU NEED FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR INTERICITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2. MONTH PERIOD), THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL. TIME TRAINING, TIME IN TRAINING FOR THE LICENSE APPLfED FOR CANNOT BE DOUBLE COUNTED UNDER E XPE RIENCE (ITEM 13),

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE 00 NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME, 13.

EXPERIENCE - A MINIMUNI OF 6 MONTHS AT ThE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRLD, FOR EACH POSITION HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE AS$1GNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONfHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

14.

FACILITY OPERATOR TRAINING PROGRAM - lNDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM:

'mk ATIFIED (ON NRC FORM "*? CR NRC *,PPROVED CIMULATG TMmi s sa vasD m Tns MsnMUM INAINING PRO.

GRAM IF "YES" IS CHECKED IN BOTH ITEMS 144 AND 14.b. THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),

AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED, NEW APPLICATIONS MUST STILL INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3, NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.8, REV,2, ARE MET, 15.

FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL, (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION EXAMI.

NATION.

16.

EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION, IF MORE SPACE IS NEEDED, USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATION, 17.

COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPLI.

CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TlON.

18, NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 19J SIGNATURES - SIGN AND DATE ITEM 194. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE, DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO THE APP PftlATE REGIONAL ADMINISTRATOR,

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$10N. W ASHINGTOer DC aut.b6, AND TO THE PAPtRIRf004K RE DUCT ION PROJECT 13160ansot. OF F tCE OF MANAGL-TO REMAIN VAllD.THIS FORM Must NOT BE ALT ERED Mt NT AND SUDGE T. W ASHINGTON. DC 20603,

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h4 CENT s#RC ADMINittimLD REQUALIFICATeoN txAmiNATsow PASS Fall

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s ami ANY I ALSE Elei *Yt4T OR OMIS$10N IN THis DOCUMENT, INCLUDING AT'T ACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMIN AL SANCTIONS.

see. I seridy uneesoneny el pertory enn tem iniormenon in this assument end ensehnwms to true end sorrect. I turther certity thei i hem noiHed my evnem empaover et. til ein pronous onwovers; (2) em trumense where I hans esen eemos by a Hegun eeut Human tervices (HH86 Certiteed Drug lesiong Laterstory of a Licenere e testireg teenny for alcohol or o sentrDated aussiense end the test soeusse essessed the eurott immes esieweehed puement to 10 C7 N Port 26;(3) env inmense where I heva teen arrem*J Nir the eso. use er possessen of e comroeied submenee esserend in 10 CF M Port 26.

one 146 ene seasons see roment er revossion et unescorted screes et e austeeritseeinv. I sine suihorue the NHC se suben the resame et enormnoimes to my empeevers ter vee m papermg retrening esegsoms, se enestry.

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] h. I samtv ches the sinne nomad indmahmi has suaesetunv eompieine the seeiin, hreneses voouwenwait to to heensed m en opercortsemne operaer pursuem so inw 10, Code et Fmie Port OS:ene some the Weswidues has e need oor en Operseer/sener Opereios amense to perioren he/her eeuened ihnen end thei the seemso. sea me maae eenews see essmmetion. l ese comtv under peneirv et posturv that she Iniormeuen en thee meevnwm and etischments h true end sorrect

] 6 mtNewt AL ONtY = 4 eertify thei tim esoge named indwiduel maois the m>prowd requalitsteten pepgram fwden esdeptions spesef m free f FJ euegwiend by esction 60 64 lost of that he/she has t'terherged tus/her heensed responsiminess competenity and efety. I esto senity unoer peresty of peflury that e.w information in this oncemerie end eitschments h true end correct.

TR AINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PReedTED OR TvPtD NAME PRINTED OR TYPLD hAME SeGe4ATURE Daft SiONATURE DAfg FOR NRC USE

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W AIVE R (ChecA or Opmplere Jtems. es appikeD/e) l MFETS REQUthtMENTS l l Dots NOT Mitt REQUIREMENTS (EspWa dwewJ on.m.oe.

os teo s, HE ADQu An i t as at GION HE ADQuanTE nB nE GION CRITTFN OPERATING ELlilBILITY MEDICAL 8'GNATV"E-"EV*L" lDalt DTHER'

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M4%T AND SUDGET st&$MINQ fO% DC 20e03 NJ Mk QP APPLICANT F ACILIT Y l F ACILITY DOCAET nut 8BE R A. MEDICAL E XAMIN ATION CERTIFICATION THiS is TO CE RTIF Y THAT THE ABOVE NAMED APPLICANT FOR AN OPEftATOR ' SENIOR OPE RATOR l eCENSE HAS SE EN E RAMINED BY A PHYSICIAN PstNT E D N AME to phraeciarif lST ATE AND LICENSE NUMBER l E AAMsN ATION DAll r

B ASED ON THE RE SULTS OF THE E X AMINAfiON INCLUDING INSORMATION F URNISHED BY THE APPLICANT. THE PHYSici AN HAS DETE RMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENE R AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPER AflON AL E RROR$ ENDANGERING PUBLIC HE ALTH AND SAF ETY I CE RTIF Y THAT IN RE ACHING THIS DETE RMih ATION THE GUIDANCE CDNT AINED IN ANSt, ANS 3 41983 OR ANSI /ANS 15 418771N380l W AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW 8Y NRC ON THE BASIS OF THE RECOMMENDATION OF TtiL.fHYSICIAN I RECOMMEND THAT THE APPLICANT'SOPERATOR LICENSE BE CONDITIONED AS FO L LOWS.

1. NO RESTRICTIONS

2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES

3. HE ARING AlD SE WDAN WHEN PE RFORMING LICENSED DUTIES

4. REST RICTED LICE NSE OR E xCEPTION.Provios detain t eien ann attach sus,portmg medicai evioense for NRC review 5 RES'rRICTION CHANCE F F4M PRE vlOUS SUBMITT AL Provice nosits beo* ano attach supportmo maaicas eveence for NRC review PwOPOSED WORDING OF RESTRICTION #8 doca 4 atevel 1

AE LATIONSHIP OF RESTRICTION TO DISOUALIF YING CONDITION IS"efly sammare how restncten we# correct the desgueWymf conprfenf KEMARKS FOR RESTRICTION CHANGE (8/oca 5 shovel B. NONMLDICAL CE RilFICAllON POWE R RE ACTORS.

THis CE RTIFIES THAT THE APPLICANT HAS BEEN FOUND TO ME ET THE SAF LGUARDS' AND Fif NESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPER ATORS NON POWER RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARD $' REOulREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS AND t HAVE NO KNOWLEDGF OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBST ANCES AS ESTABLISHED PURSUANT TO to CF R 26 s =v s atan s t a rtut Nt on owissium im mis oocuwtut escLuoimu nt racawtuts wa v et sveatct Tu cm6 amu caimmat sanc tius s ota ti+ r vNuta nNati v ut IERJUAV THAT THE iheORuateON em THIS DOCubalNT AND ATT ACMutNTlis TRut AND ComptCf.

f PRINTED N AME AND SIGN ATURE (Sener Manevement Neoresentarsee on Seret TITLE DATE in accorcance with to CF R 55 5. Commumcaiens, tms term shall be submitted to the NRC as toilows. 8 Y MAIL ADDRESSE D TO.

Regenal Admemstrator. Region i Regenal Admmistrator Region 11 Regionai Aommestrator. Region all U S Nuclear Regulatory Commissen U.S. Nuctear Regulatory Commessen U S Nuclear Reoulatory Commmen 475 Allendose Road 101 Manetta Street. Suite 3100 799 Rooseveit Hoad Kmg of Prussia. PA 19406 Arianta G A 30323 Gen tiivn. #L 60137 Regonal Admimstrator Region IV Regenal Admmistrator. Region v U.S. Nuclear Regulatory Commenon U S Nuceear Regulatory Comminen 611 Ryan Plaza Dnve Suite 1000 1450 Maria Lane. Suite 210 Arimeton. Tx 76011 Wamut Creet. CA 94596 PRiv ACY ACT ST ATEMENT Pursuant to 5 USC 552atest3L enacted mto tan by wetion 3 of the Pnvecy Act of ROUTINE USES. The moormaten may be d,sciosed to an soproprete Feoerst State, or 1974 IPubhc Law 93 5791.the followag statement is 'umished to individuais who tocai agency m the event the m'ormation md cates a vmisten or potential violaten of le*

suppsy informaten to the U.S Nuclear Regusatory Commenen on NRC Form 396 and in the ennt the mformaten moscam a veuten or armntias velaten of law and m TNs mformaten is mamtamed m a system of recbetts daugnated as NRC 16 and the course of an admimstrative or sudacial proceedmg in addition. th.s mformaten may te descritwed at 51 Federai Register 33157 (September 18.19861 transferred to an sopropriate Federal. State. and socal agency to the entent resevent and nectuarv for an NRC decis on about you.

AUTHORITY Sectens 107 and 161M of the Atomic Energy Act of 1954 as amended t42 U S C 2137 and 27010))

AHETHER DISCLOSURE ($ MANDATORY OR VOLUNTARY AND E F F E CT ON PRINCIPAL PURPOSElst ine rmaten entered on tms o rm is used to oetermme INDivtDUAL OF NOT PROVIDING INFORMATION D.iciosure is voiuntary. It the o

o whether the onysical conditen and generai heaeth of the applicant are such that they rettuetted informaten is not provided nowever. the appocat on tot a facihty operatofs will not cause operetenas errori enoangerme public hesith and sa ety. This msorma e' waior ope'ato's hcense may be Denied r

ten may be useo by the NRC staff to ottermme of the mdividual mHis the reou're

$YSTEM MANAGER ($1 AND ADDRESS Chief. Operatoe Licenung Branch OHice of ments of to CF R 55 to taae an enemmaten of to tm inued an operator's beenp Nucieer Reactor Regulation. U S Nucitar Requistory Comm'nion Washington, DC 20555 NeiC eqav Ma enage

1 DCCSURE 3 SM1ARY OF QUMES M NIC POEM 396 Medical r-% tion Certificatim Added block "!Instrictica Change Frta Prwious Sukunittal" plus Remarks meetion.

Han-Medical Certification Changed non-medical certification statement to: Power Beactors-This certifies that the applicant has been found to meet the safeguards

• and fitness for cksty requirements of this this facility for licensed operators.

Honpower-this certifies that the applicant has been fond to meet the safeguards' requirements of this facility for licensed operators and I have no knowledge of the applicant w inn the autoff levels for alcohol or controlled sabstannan as es+=h14=w pursuant to 10 CFR 26.

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DG060RE 4 SUtttARY OF CHMMS 10 HNC 1CIti 398 l

Item 4.d Added clarifying statament to indicata this is to be checked only if application is to===rvi liaanse to add additional unit (s).

4 Item 4.f Added "(Catasory)" to operating, i

i Added "teamnal".

~

r Item 4.s Added a new item " Data Passed Generic Fundamentals Examination Section".

Item 12.3 Changed wording to " Certified Startup.^.w.

Completed" for clarification.

Item 12.5 Changed wording to " Extra Person Ch Shift In Control Room (13-week minima)" for clarification.

l s

Itam 12.5a Added a new item " Time on Shift Atxrve 20E Power (6-week miniaam)".

Item 14.a Added the words "That Is Based Upon A Systeen Aw.vwe.

I to Tr=iaia=" for clarification.

Item 15 Added "Date and Beault of Heat Recent NRC Administered Hegualification Enemination",

t' Itam 19.a Added the wording "I Aarther certify that I have notified my current employer of t (1) all-prwicus employers: (2) any instance where I have been tested by a Health and ihman Services (HHB) Certified Dms Testing Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results M the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance where I have been arrested for the sale, use or possession of a centrolled substance described in 10 CFR Part 26; and (4) any reemens for removal or zwvocation of unescorted a - a at a nuclear facility".

Item 19.b and Item 19.c tioved 19.b ard 19.c tesother. Applicable box aust now be checked. Also added block for typed name of Training Coordinator and Senior Management Representative on Site.

POR 15C USE Under waiver cetesory added "teaMaal".

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