ML20217J213
Text
Multiple Addressees - Letter Dated: April 2, 1998 IDENTICAL LETTERS ADDRESSED TO THE TRAINING MANAGERS OF THE REGION lli FACILITIES LISTED: ON THE ATTACHED DISTRIBUTION PAGE.
SUBJECT:
REVISED NRC FORMS 398 and 396
' Enclosed is one copy each of the revised forms: NRC Form 398, Personal Qualifications Statement - Licensee (Enclosure 1), and NRC Form 396, Certification of Medical Examination by Facility Licensee (Enclosure 2). Due to an error on the instructions for Form 398, addendum instructions for completing the form are provided as Enclosure 3 to this letter. You should use these forms immediately for any new applications or license renewals that you are sending to the U. S. Nuclear Regulatory Commission. provides a summary of the detailed changes to these forms. On Form 398, you should note that applicants are now required to provide evidence on the significant control manipulations performed as trainees at the facility for which the license is being sought. On this matter, you should refer to NRC Information Notice No. 97-67, dated August 21,1997.
On Form 396, the applicable guidance used in making the medical determinations needs to be indicated. Also, be advised that the NRC staff has recently approved Revision 3 of Regulatory Guide 1.134, " Medical Evaluation of Licensed Personnel at Nuclear Power Plants," which endorses ANSI /ANS-3.4-1996," Medical Certification and Monitoring of Personnel Requiring Operator Licenses for Nuclear Power Plants." A notice in the Federal Register will be out shortly.
Further, you should keep a copy of Enclosure 3 with the Form 398 until new forms are printed and distributed. Your office can obtain additional copies of both forms by contacting Beverly Martin by telephone on 301-415-5877 or by writing to her, U.S. Nuclear Regulatory Commission, Office of the Chief Information Officer, Mail Stop T-6-F-33, Washington, D.C. 20555-0001, or e-mail BAMi@NRC. gov.
If you have any questions regarding these forms, please contact Mary Ann Bies of my staff at 630-829-9711.
Sincerely, Original signed by:
Melvyn N. Leach, Chief Operator Licensing Branch i
l : NRC Form 398 - Personal Qualifications Statement - Licensee
) : NRC Form 396 - Certification of Medical ExamintAion by Facility Licensee 1 : Addendum Instruction for NRC Form 398 : Description of Changes to NRC Forms 398 and 396 Distribution:
I See Attached List DOCUMENT NAME: P:\\398-396.rev I
To receive a ce >y of this document, Indicate in the box "C" = Co:>y w/o attach /enci"E" = Copy with attach /enci"N" = No copy OFFICE Rlll:DRS l6 Rill:DRS NAME MABies:mab,,# MNLeachM DATE 04/O//98 04/ N98 OFFICIAL RECORD COPY 3 804060228 980402 PDR ADOCK 05000155
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Multiple Addressees-Letter Dated: April 2. 1998 Region ill Facility Training Managers as Listed Below identicalletters sent to:
D. G. Lacroix, Big Rock Point, Docket No. 50-155 "J. B. Walker, Braidwood, Docket Nos. 50-456; 50-457'
.T. L. Schmidt, Byron, Docket Nos. 50-454; 50 455:
J. F. Palchak, Clinton, Docket No. 50-461
.D. C. Loope, Donald C. Cook, Docket Nos. 50-315'50-316 R. A. Simpkins, Davis-Besse, Docket No. 50-346 J. S. Almon, Dresden, Docket Nos. 50-237; 50-249 '
K. D. Young, Duane Amold, Docket No. 50-331 -
- 4. W. Davis, Fermi, Docket No. 50-341 J. J. Brown, Kewaunee, Docket No. 50-305
. -D. P. Sanchez, LeSalle, Docket Nos. 50-373; 50-374 M. A. Mitchell, Monticello, Docket No. 50-263
./. M. Haas, Palisades, Docket No. 50-255-E. M. Root, Perry, Docket No. 50-440 -
...W. P. Walker, Point Beach, Dockel Nos. 50-266; 50-301 '
. M. J. Ladd, Prairie Island, Docket Nos. 50-282: 50-306 -
F. S. Tsakeres, Quad Cities, Docket Nos. 50-254 50-265 L. L. Schmeling, Zion, Docket Nos.- 50-295, 50-304 1
cc w/encls: Site Vice President or Station Manager, as appropriate Distribution w/encis:
PUBLIC-lE42
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INSTRUCTIONS FOR COMPLETING NRC FORM 398, PERSONAL QUALIFICATION STATEMENT-LICENSEE TO REMAIN VALID. THIS FORM MUST NOT BE ALTERED 4,
TYPE OF APPLICATION a.
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 RECEIVED UP TO THE DATE OF THIS APPLICATION NOTE: SEE ITEM 12 -THERE IS AN EXCEPTION ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN PLEASE WRITE " WITHDREW' NEXT TO "NEW "
FOR 4 b THROUGH 4 e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION. TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION NOTE: SEE ITEM 12 THERE IS AN EXCEPTION b.
RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE.
c.
UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO.
d.
MULTI-UNIT "X"IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CURRENT LICENSE TO ADD AN ADDITIONAL UNIT.
e.
REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.
f.
WAlVER REQUESTED "X" THE APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).
D.
DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES) - THIS IS NOT APPLICABLE TO RESEARCH REACTORS OR LICENSES LIMITED TO FUEL HANDLING ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINATION SECTION OF THE WRITTEN EXAMINATION WAS PASSED IF THE GFES WAS 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 RQ1 INCLUDE INSTRUCTOR CERTIFICATlON EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.
11.
EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL 1 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 RECEIVED. USING THE DEGREE CODE PROVIDED FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDlNG PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION. DIESEL MECHANIC SCHOOL, ETC. INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED IF ADDITIONAL SPACE IS NEEDED. CONTINUE UNDER COMMENTS (ITEM 17) 12.
FACILITY OPERATOR TRAINING PROGRAM CHECK THE APPROPRIATE BOX IN ITEMS 12 a AND 12 b NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD.
NOTE IF "YES"IS CHECKED IN BOTH ITEMS 12 a AND 12 b THEN ITEMS 13 (TRAINING),14 (EXPERIENCE). AND 15 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED, WITH THE EXCEPTION OF BLOCK 13 3 c ALL NEW2PPLICATIONS (ITEM 4 a) MUST INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS WHICH AFFECT REACTIVITY OR POWER LEVEL UNDER ITEM 13 3 c 13.
TRAINING - ALL NEW APPLICATIONS MUST PROVIDE EVIDENCE THAT THE APPLICANT, AS A TRAINEE, HAS SUCCESSFULLY MANIPULATED THE CONTROLS OF THE FACILITY FOR WHICH A llCENSE IS SOUGHT. AT A MIN! MUM. FIVE SIGNIFICANT CONTROL MANIPULATIONS MUST BE PERFORMED WHICH AFFECT REACTIVITY OR POWER LEVEL UNDER ITEM 13 3 c. IN ACCORDANCE WITH 10 CFR SS 31(b), LIST THE FIVE SIGNIFICANT CONTROL MANIPULATIONS IN ITEM 17.
ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM 13 6 PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING FOR CLASSROOM OR SIMULATOR TIME UNDER ITEMS 131,13 2. OR 13 3 14.
EXPERIENCE A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR EACH POSITION HELD, COMPLETE ITEM 15. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PART!CULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.
15.
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, 16.
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 FACILITY REQUALIFICATION EXAMINATION 17.
COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CtARiflCATION FOR OTHER ITEMS ON THE APPLICAT!ON FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICATION 18.
NRC FORM 396,CERTIFICATlON OF MEDICAL EXAMINATION BY FACILITY LICENSEE MUST ACCOMPANY THIS APPLICATION UNLESS A WAIVER OF THE MED: CAL EXAMINATION IS BEING REQUESTED 19, SIGNATURES SIGN AND DATE ITEM 19 a 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 AND 396 (ORIGINAL AND TWO COPlES EACH) TO THE APPROPRIATE REGIONAL ADMINISTRATOR. (SEE REVERSE SIDE FOR ADDRESSES OF REGIONAL ADMINISTRATORS AND FOR THE PRIVACY ACT STATEMENT.)
NRC FORM 398 (to1997)
ADDRESSES OF REGIONAL ADMINISTRATORS in accordance with 10 CFR 55 5. Communicatons, this form shall be submitted to the NRC as follows: BY Mall ADDRESSED TO:
REGIONAL ADM6NISTRATOR, REGION 1 REGIONAL ADMINISTRATOR, REGION 11 REGIONAL ADMINISTRATOR, REGION ill U. S. NOCLEAR REGULATORY COMMISSION U S. NUCLEAR REGULATORY COMMISSION U S. NUCLEAR REGULATORY COMMISSION 475 ALLENDALE ROAD ATLANTA FEDERAL CENTER 801 WARRENVILLE ROAD KING OF PRUSSIA, PA 19406-1415 61 FORSYTH STREET S.W SUITE 23T85 LISLE, IL 60532-4351 ATLANTA,GA 30303d415 REGIONAL ADMINISTRATOR. REGION IV U S. NUCLEAR REGULATORY COMMISSION NON-POWER U. S. NUCLEAR REGULATORY COMMISSION OPERATOR LICENSING BRANCH, HQ U 5. NUGLEAR REGULATORY COMMISSION 611 RYAN PLAZA DRIVE, SutTE 400 DIVISION OF REACTOR CONTROLS AND NON-POWER REACTORS AND DECOMMISSIONING ARLINGTON, TX 76011 8064 HUMAN FACTORS PROJECT DIRECTORATE HQ WASHINGTON, DC 20555-0001 DIVISION OF REACTOR PRdGRAM MANAGEMENT WASHINGTON, DC 20555-0001 PRIVACY ACT STATEMENT Pursuant to U.S C. 552a(s)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Pubhc Law 93-579), the following is fumished to individua supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. This information is maintained in a System of Records design NRC 16 and desenbed at 58 FederalRegrster 36465 (July 7,1993), or the most recent FederalRegrster "Repubhcation of Systems of Records Notices" that is available at the NRC Public Uocument Room,publicaton of the Nuclear Regulatory Commission's
- Wxhington, D.C.
Gelman Bunng, Lower Level,2120 L Street NW, 1.
AUTHORITY. 42 U.S.C. 2137 and 2201 (1)(1988).
2.
PRINCIPAL PURPOSES, The informaton will be collected and evaluated for determining licensing ehgibihty and to generate stattstical da on hcensing actions.
3.
ROUTINE USES, Information entered on this form may be used to: (a determine if the individual meets the requirements of 10 CFR Part 55 to be issued an operator's hcense; (b) provide researchers with information for s)tatistical evaluations related to sele operators; (c) provide facehty management with sufficent informaton to enroll you in the licensed operator ruguakficaten program; and (d) provide for cxamination and testing matenal and obtain results from contractors. Information may also be disclosed to appropriate Federal, State, local, or Fo agences to the extent relevant and necessary for an NRC decision about you or in the event the infortnation andcates a violaton or potential violation or law. In addition, information may also be disclosed in the course of an administrative or Judicial proceeding, to a Congressional office to respond to their inquiry made at your request, or to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDMDUAL OF NOT PROVIDING 4.
in voluntary. However, if the information requested is not provider!, NRC will not be able to evaluate whether the apphcation meets the requirements of 10 CFR Part 55.
- 6. - SYSTEMS MANAGER (S) AND ADDRESS. Chief, Operator Licensigashington DC 20555-0001 Branch, Div Nuclear Reactor Regulation, U S. Nuclear Regulatory Commission,
^-
e a
NRC FORM 300 U S. NUCLEAR REGULATORY COMMIS$lON APPROvtD BY 00W: NO. 31"" ""**
EXPIRES: 10/31/3000 DATE RECErVED Estenated burden per response to compey reh ese rvormalen uwen (To be co@ed by NRO 10 CFR M.31. % 36.
request 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> NRC regares eue informaten to ensure vist apphcen.te/hcensees,.m.est as sie ree.mroments for tasune 'me.cea.r operosa.r M 47, and 66 67 Namin.=n and R=== Mmmere.M euroen eu m = =OC uc=.
no ro d co r*em
=eom sN PERSONAL QUALIFICATION STATEMENT-LICENSEE emo a -.Y Comm n.
Papennork Reibcten (31
). Ofhos of Management and suageL Weehrunnet DC N an evormason -me-m aces not espiny e cmere venabM6 cortog rasreer. to NRC nos cenad or eponsor, TO REMAIN VAUD, THIS FORM MUST NOT BE ALTERED r
erus e person a roi roomrod to respond to. the comecson L APFUCANT'S FULL NAME (Last, forst, Middle) AND ADDRESS (include ZIP Code)
- 4. TYPE OF APPUCATION IChact apptwoble bomonf l HOT l l COLD
~
e NEW l
- f. WAlVER REQUESTED uusts4 on Reverse /
- b. RENEWAL
- 1. WRTTTEN (Category)
- c. UPGRADE
~
- d. MULTI-UNIT LAMEND TO INCLUDE A00tTIONAL UNITl 3 ELIGIBlWTY e REAPPLICATION 4 MEDICAL 1 FIRST 6 OTHER 2 CITIZENSHIP
- 3. BaRTH DATE 2 SECOND MONrH DAY Yt AA 3 THIRD FUNDAM N ALS MINATION s UNITf D STATES SECTION llF APPUCABLE) l l
l l
l
- b. OTHER ISpecWI
- 6. PREVIOUS UCENSE(S) HELD
- 5. TYPE OF LICENSE APPUED FOR a OPERATOR
- s. DOCKET NUMBER RO sno
- b. UCENSE NUMBER
' ((^* 7
- d. FACILITY DOCKkT NUMBER f
I i
~
b SEN OR OPERATOR
~
- c. UMrit O SRO te g, fuel Hamiler)
- 10. CURRENT POSETION AT FACILITY
- 7. NAME ANO ADORESS OF APPUCANT'S EMPLOYER (IncludellP Code) l AUXILIARY UNIT OPER-s.
PLANT SUPERINTENDENT ATOR/ TRAINEE / TURBINE ASSISTANT PLANT SUPERINTENDENT BUILDING 400tPMENT b.
OPERATOR INON U2NS-SHIFT SUPERVISOR go opggj7pgj c.
STAFF ENGINEER
- j. OTHER (Spect&J d
SHIFT TECHNICAL ADVISOR / SHIFT ENGINEER
- 5. NAME OF APPUCANT'S FACILITY l F ACIUTY DOCKET NUMBER e.
f.
INSTRUCTOR 9 AOOfTIONAL FACILITY OOCKETS IMutts-unit Licenses) g SENIOR CONTROL ROOM OPERATOR h.
CONTROL ROOM OPERATOR
- 11. EDUCATION
- s. H4GMSCHOOL
- e. IIAAJOR AREAts) Of STUDY
,Z My DEGREE CODES
- d. VOCATIONAL / TECHNICAL T8 TNo4 (To be used for " HIGHEST
- "^"
A= cean DEGREE
- obtemed)
ENGINEERING (FlELDS)
GRADUATE 0 NONE GED EQUIV ALENCY 1
- CERTIFICATE OTHER 2 - ASSOCIATE 3 BACHELOR b NUMIM ft UF 4 MASTER 6 - DOCTORAL "06 LE"Gs 0
- 12. FACIUTY OPERATOR TRAINING PROGRAM h Cf meted TON N4C sORM 474 *$AMULAr& #ACittfY flON FACILrrY IS YES NO
& e#0 ACCREDITED OPERATOft TRANNG YES NO ggmygNg g5 PeOGRAM fHAT 19 8AeED UPON A SYSTEMS APPROACH TO TRANNQ
- 14. EMPERIENCE (DO NOT DOUBLE COUNT-SEE INSTRUCTIONSI
- 13. TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS) e uom m Amo vt An a samme e wwN &
O VEAR b NUiJETR mou To G amsme NJ 7o Of WEEK 5 1 - NUCLEAR POWE R PLANT FUNDAME NTALS 1 RO 2 - EOOWPPWO 2 - PLANT SYSTEMS CLASSROOM 3 EWS/PPWS OSSE RVATION 4 ERS/CRW 6 OTHER (SpecW1 3 - OPERATING PRACTICE CONTROL ROOM OPE RATIONS ON SHIFT FOSS8L
$8MULATOR OPERATING (Jncludes Caseroom; 6 OPERATOR
&lMULATOR NAMES py gg%4
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.,u a y - m..a
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T. SUPE RVISOR
,L4 y J 7:6,e * (G 8 PLANT STAFF f i h, h /kl$ y j$.y(xr e,
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4 9 OTHER (SpecW) crnTww o sT AaTue l
lYES l lNO
.g.yg^Qig '
p gr
' p COGARAERCIAL NUCLEAN lincluding ResearcWTent Reactor)
PnconAu cOMetrito 3 fffyQ TQ ' * '
e NUMeta os sicA% CANT coNTnot MAgg
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10 REACTOR OPERATOR (Lkensed)
MANT 5
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11 SENIOR OPERATOR (Leensed) 4 - S"s0 INSTRUCTION 12 SHIFT SUPERVISOR (Ucensed) 5 eirtaa reason oN eHriIN CONfMUL ROOM 13 STAFF / SHIFT ENGINEER (Ucensed)
'o intra :.--- "_a a $ Q #'#'18 7' N 0*'"
14 OPERATOR (Nontwensed) 8 - RE QUALIFICATION 16 PLANT STAFF
'"O# WNE 16 OTHER ISpecW) letC FORM 300 (10w100T)
i 1J. EXP M DETAR5-
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES l
1s. FOR AsNEWALS ONLY b.
DATE AND RESULT OF MOST
- c. HOURS OPERATED FACluTY:
RECENT FACILITY PASS Fall HEOUAUFICATION EXAM 11, COMMENTS ISpecify the Item number to which you are elaborating. Attach addstionalsheets if necessary)
- 18. NteC FORM 396, CERTIFICATION OF MED8 CAL EXAMINATION SY FACILITY LaCENSEE, tS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVit AND CRIMINAL SANCTIONS.
19a. I ecrtify under penalty of perjury that the informahon 6n this tiocument and attachments is true and correct. I further certify that I have nohhed my current employer of- (1) all previous employers;(2) any instance where i have been tested by a Health and Human Services (HH$) Certsfeed Drug Testmg Laboratory or a Licensee a tentmo facihty for skohol or a controlled substance. and the test reautte euceeded the cutoff levels estebbshed pursuant to to CFR Part 26. (31 any instance where i beve been orrested for the sale, une or possession of a controlled substance dencnbod in 10 CFR Part 26. and (el any reasons for removal or revocat#on of unescorted souess at a nuctaar f acifery, I also authorire the NRC to submit the results of exammatione to my employers for use in proper 6ng retroemng programa, se necessary.
SIGNATURE-APPLICANT l DATE CHECK APPLICABLE BOX
- b. I certify that the above named mdividual has successfuoy completed the facility licensees requir6:nonts to be licensed se an Operator / Senior Operator pursuant to Tette 10. Code of Federal Regulations. Port 66; and that the indsv6 dual has a need for an Operator / Senior Operator heense to perform his/her assigned dutwo and that the facihty will be made available for examinatson.
I steo cerufy under penalty of perjury that the information in th6. document and attachments se true end corfect.
- c. RE NEWAL ONLY - t certify that the above named mdtvidual meets the approved regoshficatson program fwrth excepr# orts noted in frem f 7) as required by sectson 60.64 li-1) of 10 CFR 60, and that he/she has discharged his/her licensed responsitulaties competently and safely. I also certify under penalty of perjuty that the information in this document and I
attachments 6e true and correct;,
TRAINING COORD4NATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPED NAME AND TITLE PRINTED OR TYPED NAME AND TITLE SIGNATURE lDATE lDATE SIGNATURE
,OR N C u.E WAIVER (Check or Complete items, as applicable) l MEETS REQUIREMENTS l l DOES NOT MEET REOVIREMENTS Explain below; o-o.
m e,y GTE GOW WK500WtMT Me mAcouAmns um WRITTEN OPERATING ELIGiBfuTY MEDICAL SIGNATURE 4EVIEWER,
lDATE OTHER f NRC FORM 388 (101987),
O O
NRC FORM" 396 U.S. NUCLEAR REGULATORY CO:.: MISSION APPROVED BY OM3: NO. 3150-0024 EXPIRES: 12/31/1999 Estmeted buroen per rssponse to ccmpty with this mformatm collecten request (3-1996) 10 CFR 55 21. 55 23.
15 mmu12s NRC requrtstne mformaton to det@rmine that the phys; cal condim and 55 25. 55 27,55 31 health of operator licensees is such that the appleant would not be expected to cause operational errors endangenng the public health and safety. Fonward comments 55 33. 55 57 regarding burden estrnate to the information and Recorcs Management Branch (T-6 F33).U.S NuclearRegulatoryCommission. Washington, DC 205550001. and to CERTIFICATlON OF MEDICAL EXAMINATION ine Paperwon Reducim Pro cusi5ac024). Orree or u.nagemoni.nd Budget, Washegtort DC 20503 If an information collecta does not d splay a currentty vahd BY FACILITY LICENSEE OMB control number. NRC may not conduct or sponsor, and a person is not requred to respond to, the informate collects N.tME OF APPLICANT FACILITY FACILITY DOCKET NUMBER A. MEDICAL EXAM INFORMATION THIS IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR / SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN AND THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIRE %iENTS FOR LICENSED OPERATORS AT THIS FACILITY.
PRINTED NAME (orphyseen)
STATE AND UCErdSE NUMBER MOST RECENT MEDICAL EXAMINATION DATE BASED ON THE RESULTS OF THE PHYSICALEXAMINATION.INCLUDINGINFORMATIONFURNISHEDBY THE APPLICANT.THE PHYSICIAN HAS DETERMINED THAT THE APPUCANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE SUCH THAT THE APPLICANT WOULD NOT BE EXPECTED TO CAUSE OPERATIONAL ERROR 3 ENDANGERING PUBLIC HEALTH AND SAFETY I CERTIFY THAT IN REACHING THl3 DETERMINATION. THE GUIDANCE CONTAINED IN ANSUANS 3 4-1996 ANSUANS 3 4-1983.OR ANSUANS15 41988(N380)WAS FOLLOWED AS ENDORSEDBY THE APPLICABLE NRC REGULATORY GUIDE. AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC IF THE GUIDANCE IN THE APPROPRIATE ANSUANS DOCUMENT IS NOT COMPUED WITH AN ACCEPTABLE ALTERNATIVE METHOD, WHICH HAS DEEN APPROVED DY NRC,WAS USED ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. IT IS REQUESTED THAT THE APPLICANTS OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES 3 HEARING AlD BE WORN WHEN PERFORMING LICENSED DUTIES 4 RESTRICTED LICENSE OR EXCEPTION - Provide explanation and attach supporting rnedical evidence for NRC review.
5 RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL - Provide explanation for restnction change and attach supportmg rnedical evidence for NRC revew 6 INFORMATION ONLY PROPOSED WORDING OF RESTRICTION (SJock 4 above)
GUIDANCE USED IN REACHING THIS DETERMtNATION ANSUANS 3 4 - 1996 ANSI /ANS 3 4 1983 ANSUANS 15 4 - 1988 (NON-POWER)
OTHER (Spech)
RELATIONSHIP OF RESTRICTION TO DISQUALIF YING CONDITION (ane#y andcate how restncfm w# twoct the daque@ng condhon)
EXPLANATION FOR RESTRICTION CHANGE (SJock 5 above)
B. CERTIFICATION ANY FALSE STATEMENTOR OMISSIONIN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
PRINTED NAME AND TITLE (Serwor Afanagement Represente0ve ort Site) l SIGNATURE lDATE in Eccordance with 10 CFR 65 S, Cornmurucations, this original form shall be sutwnstted to the appropnate NRC omes as follows: BY MAIL ADDRESSED TO:
REGIONAL ADMINISTRATOR, REGION I REGIONAL ADMINISTRATOR, REGION 11 REGIONAL ADM!NtSTRATOR, REGION lil U S NUCLEAR REGULATORY COMM!SSION U.S NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION 475 ALLENDALE ROAD ATLANTA FEDERAL CENTER 801 WARRENVILLE RD KING OF PRUS$1A PA 19406-1415 61 FORSYTH STREET, S W, SUITE 23T85 LISLE. IL 60532-4351 ATLANTA, GA 30303-3415 REGIONAL ADMINISTRATOR, REGION IV U S. NUCLEAR REGULATORY COMMISSION NON-POWER U S NUCLEAR REGULATORY COMMISSION OPERATOR UCENSING BRANCH, HQ U.S. NUCLEAR REGULATORY COMMr$SION 811 RYAN PLAZA DRIVE, SUITE 400 DIVISION OF REACTOR CONTROLS AND NON-POWER REACTORS AND DECOMMISSIONING ARLINGTON, TX 760118064 HUMAN FACTORS PROJECT DIRECTORATE, HQ WASHINGTON. DC 205554001 DIVISION OF REACTOR PROGRAM MANAGEMENT WASHINGTON. DC 20555-0001 NRC FORM 396 (3-1996)
PRINTED ON RECYCLED PAPER
ENCLOSURE 3 ADDENDUM INSTRUCTION FOR NRC FORM 398 Applies to the Instructions for item 4.g, on the " Type of Application":
g.
DATE PASSED GENERIC FUNDAMENTALS EXAM SECTION (GFES)
The last sentence of 4.g states: "This does not include instructor certification examinations or requalification examinations".
This statement is in error and is not in accordance with Interim Rev. 8, ES-205, section B, third paragraph, which states as follows:
" Applicants do not need to take the GFE (nor obtain a waiver) if they were previously issued an RO or SRO license or an instructor certification (underline added] based on a site-specific written examination (on the same type of facility) that was administered between February 1982 and November 1989 and included the material covered by the GFE. Applicants who were issued a license before 1982, will have to take the examination or apply for a waiver in accordance with ES-204.
The last sentence of 4.g should read,"This does not include reaualification examinations."
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ENCLOSURE 4 CHANGES TO NRC FORMS 398 AND 396 NRC Form item Description of Changes Number Number 398 4.g See Enclosure 3.
398 13 instruction Sheet: All new applications must provide evidence in accordance with 10 CFR 55.31(b) that the applicant, as a trainee, has successfully manipulated the controls of the facility for which a license is sought. This section was changed to read as follows:
"At a minimum, five significant control manipulations must be performed which affect reactivity or power level under item 13.3c.
list the five sianificant control manipulations in item #17."
398 18 Instruction Sheet - changed to read: "NRC Form-396, Certification of Medical Examination by Facility licensee must accompany this application unless a waiver of the medical examination is beina reauested.
398 NA Form: The OMB expiration date is now 10/31/2000. In the OMB block the following was added: "If an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor. and a person is not reauired to respond to. the information collection."
398 NA Form and Instructions: Top and Bottom left-hand side have date changes to 10-199L
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ENCLOSURE 4 - CHANGES TO NRC FORMS 398 AND 396 (CONTINUED)
- NRC Form item Description of Changes Number Number 396 Item A Medical Exam information - statement regarding safeguards and fitness for duty requirements has been moved from item B to be included with the statement under A - Medical Exam Information as noted below:
"This is to certify that the above named applicant for an operator / senior operator license has been examined by a physician and that the aoolicant has been found to meet the safeauards an_i fitness for duty reouirements for licensed operators at this facility."
lte m A Below the physician name,...... line, the word " physical" has been added:
" Based on the results of the physical examination, including.,
in this same paragraph it states as follows: "I certify that in reaching this determination, the guidance contained in ANSI /ANS 3.4-1996. ANSI /ANS 3.4-1983. or ANSI /ANS 15.4-1988 (N380) was followed.. "
Item B B. NONMEDICAL CERTIFICATION (old form) has been changed to: B. CERTIFICATION (new form) 396 NA Top and Bottom left-hand side of the form have date changes to
.3-1998 396 NA Top right comer - OMB expiration date changed to : 12/31/1999 2
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