NRC Generic Letter 1983-12
FEB 2 4 1983 TO ALL POWER AND NONPOWER REACTOR LICENSEES, APPLICANTS
FOR AN OPERATING LICENSE, HOLDERS OF CONSTRUCTION
PERMITS AND NSSS VENDORS (GENERIC LETTER -83-12)Gentlemen:
Subject: Issuance of NRC Form 398 -Personal Qualifications Statement
-Licensee Enclosed is a copy of the new NRC Form 398 -Personal Qualifications Statement Licensee.
This form must be submitted by all applicants for operator and senior operator licenses under 10 CFR 5Find applicants for instructor certificates.
No other information or documents are required beyond that which is requested in the instructions and the form itself.Please read all instructions carefully before completing this form. Note that the form is to be submitted in triplicate.
All applications for licenses (including new applications, renewals, upgrades, reapplications and amendments to licenses)
are to be submitted on Form 398 beginning no later than one-month from the date of this letter. To insure that our records are complete and accurate, we request that the Initial submittal of Form 398 by an applicant be completed with respect to all infor-mation requested.
Subsequent submittals of Form 398 require completion only of that information that has chanqed since the previous submittal of this form, per the instructions provided.
Questions regarding proper completion and usage of Form 398 should be directed to your appropriate Regional or Headquarters Operator Licensing Branch staff.Requests for Form 398 should be directed to Vivian Miller, Nuclear Regulatory Comnission, Document Management Branch, M.S. W-548, Washington, DC, 20555.Allow two weeks for delivery.
Copies of this form can be duplicated, if necessary.
This request for information was approved by the Office of Manageipent and Budget under clearance number 3150-0090, which expires on August 31, 1985.Sincerely, Darrell G. Eisenhut, Director X Q2 52 Division of Licensing Enclosures:
XZ4 Qfac4kj NRC Form 398 V Personal Qualifications S tement -LFFens.e OFFICE Lcne ................
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URCFORM318
4 OFFI IAL RECORD COPY USGPO: 1981-335-960
,-,. J l-~INSTRUCTIONS
FOR COMPLETION
OF i NRC FORM 398, PERSONAL QUALIFICATIONS
STATEMENT-
LICENSEE NEW APPLICANTS:
Complete each category of the form completely, following the instructions below.RENEWAL, UPGRADED, MULTI-UNIT, AND REAPPLICATION
APPLICANTS:
Complete all Information that has changed since your previous submittal of an NRC Form 398. In addition, be sure to complete the following information:
I -YOUR FULL NAME 5-TYPE OF LICENSE APPLIED FOR 4-TYPE OF APPLICATION
6- PREVIOUS LICENSES AND/OR DOCKET NUMBER HELD SPECIFIC INSTRUCTIONS
FOR ITEMS 11 -17: 11 -EDUCATION:
Indicate both academic and vocational/technical post high school education.
For MAJOR AREA(S) OF STUDY, Indicate the number of years spent In each collere curriculum and the highest degree received, using the degree code provided.
For VOCATIONALJTECH-
NICAL education, Include programs such as nuclear power school, military training, air conditioning/refrigeration, diesel mechanic school, etc. In-dicate the number of months in each program and whether a certificate or degree was awarded. If additional space is needed, continue under ITEM 15.12 -TRAINING:
In this item indicate the training you have received to meet the requirements of ANSI N18.1/ANS
3.1. The breakdown of training in this category parallels the ANS standards:
please refer to the standards If you need further clarification.
Include both beginning and com-pletion dates and the total number of weeks spent in each type of training.
NUMBER OF WEEKS is provided, in addition to beginning and comple-tion dates, to account for Intermittent training Ifor example, four weeks of classroom training spread over a two month period). Therefore, the date columns.may Indicate a larger time span than the actual number of weeks spent in full-time training.All requalification training time Is to be accounted for in the REQUALIFICATION
item. Please avoid "double listing" recording all time spent in requallficatlon training under item 12.6, REQUALIFICATION, even though It may include classroom or simulatortime.
13 -EXPERIENCE:
For each position held, complete item 14.14 -EXPERIENCE
DETAILS: Include position title, facility, and a brief description of duties performed while serving In that position.
If more space Is needed, use item 15, or if necessary attach additional information.
15 -COMMENTS:
Use this space to include any extra information or clarification for other items on the application form. If the space provided is not sufficient, you may attach extra Information with your application.
16 -NRC FORM 396, CERTIFICATION
OF MEDICAL EXAMINATION:
Include a completed NRC Form 396 with each application In order to limit delays in issuing licenses.
If this Is not possible, place an "X' in Item 16b, and forward the form as soon as possible:
make sure all items are completed.
17 -SIGNATURES:
Sign and date item 17a. Obtain your Training Coordinator's signature and that of your highest level of corporate man-agement for plant operations.
DETACH THESE INSTRUCTIONS
AND SUBMIT THE COMPLETED
NRC FORMS 398, IN TRIPLICATE
AND 396 TO: Branch Chief, Operator Licensing Branch or the appropriate Regional Administrator.
PRIVACY ACT STATEMENT Pursuant to U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following is furnished to Individuals who supply information to the U.S. Nuclear Regulatory.
Commission on NRC Form 398. This Information is maintained in. a system of records designated as NRC 16 and described at 46 Federal Register 46717 (September
21,19811.1. AUTHORITY.
Section 107 and 161(l) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2137 and 2201 (1)).2. PRINCIPAL
PURPOSE
S.
The Information will be collected and. evaluated for determining licensing eligibility and to generate statistical data and reports on licensing 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 license; (b) provide researchers with Information for statistical evaluations related to selection, training, and examination of facility operators; (c) provide facility management with sufficient Information to enroll the individuals in the licensed operator requalification program; (d) provide for examination and testing material and obtain results from contractors.
4. WHETHER DISCLOSURE
IS MANDATORY
OR VOLUNTARY
AND EFFECT ON INDIVIDUAL
OF NOT PROVIDING
INFORMATION:
Disclosure Is voluntary.
However, If the Information requested Is not provided, NRC will not be able to evaluate whether the applicant meets the requirements of 10 CFR Part 55.S. SYSTEMS MANAGERS AND ADDRESSES:
Chief, Operator Licensing Branch Regional Administrator, Region I Regional Administrator, Region 11 Division of Human Factors Safety U.S. Nuclear Regulatory Commission U.S Nuclear Regulatory Commission Office of Nuclear Reactor Regulation
631 Park Avenue 101 Marietta Street, Suite 3100 U.S. Nuclear Regulatory Commission King of Prussia, PA 19406 Atlanta, GA 30303 Washington, DC 20555 Regional Administrator, Region Ill Regional Administrator, Region IV Regional Administrator, Region V U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission
799 Roosevelt Road 611 Ryan Plaza Drive, Suite 1000 1450 Maria Lane, Suite 210 Glene Ellyn, IL 60137 Arlington, TX 76011 Walnut Creek, CA 94596 p-V U_.10 CER 55.10 Twerps. s -A -A.^ ..............................
l^AjA.l ........ s NFIC. Formn2981'
0 o -58.10 ANE 58.33 .US. NUCI,/RE0ULATORY
COMMISSION
PERSONAL QUALIFICATIONS
STATEMENT-LICENSEE
._JApproved by OMB DATE RECEIVED (re Co*pIDr 3150.00901y IVRO) (AA)1. APPLICANT'S
FULL NAME fLatr fit, middtle) (AB) 4. TYPE OF APPLICATION
l-"Xapp-lcdble boxes) (AHI a. NEW a. REAPPLICATION
ADDRESS OR RFD NUMBER (AC) _ -HOT 1-FIRST 2-COLD 2-SECOND CITY (ADI ISTATE(AE)IZIP
CODE IAF) b. RENEWAL 3-THIRD_A REAPPLICATION
WAIVER REQUESTED--C. UPGRADE fI. if an reere 2. CITIZENSHIP
JAG) 3. BIRTH DATE IAGI d. MULTI-UNIT -ORAL a. UNITED STATES MONTH DAY 2-WRITTEN (CtWegory
...b. OTHER (Specify)
I I I I 3-SIMULATOR
5. TYPE OF LICENSE APPLIED FOR JAI) S. PREVIOUS LICENSEISI
HELD Al) -I a. OPERATOR a. DOCKET NUMBER b LICENSE NUMBER l MONTH RDAYTAION
R l d. FACILITY DOCKET NUMBER b. SENIOR OPERATOR 56 C. LIMITED SRO b*.g. Fuel Handler)Ad INSTRUCTOR
CERTIFICATION
I 7. NAME OF APPLICANT'S
EMPLOYER (AKM 10. CURRENT POSITION AT FACILITY (AS)_ .PLANT SUPERINTENDENT
I. AUXILIARY
UNIT OPERATORI ITRAINEE/TURBINE
BUILDING/ADDRESS IAL) b. ASSISTANT
PLANT SUPERINTENDENT
EQU IPMENT OPERATOR_ INONIJCENSED
OPERA TORi c. SHIFT SUPERVISOR
CITY (AM) ISTATEIANI
IZIP CODE (AOl d. STAFF ENGINEER ). OTHER ISpciW .I a. SHIFT TECHNICAL_ ADVIOADVISOR/SHIFT
ENGINEER _S. NAME OF APPLICANT'S
FACILITY (API FACILITY DOCKET f. INSTRUCTOR
IN Ag. SENIOR CONTROL ROOM 9. ADDITIONAL
FACILITY DOCKETS fMulti-Unit LkenJj JARI OPERATOR h. CONTROL ROOM OPERATOR 11. EDUCATION (AT)a. HIGH SCHOOL C. MAJOR AREA(S) OF STUDY N UMBER HIGHEST DEGREE CODES tTo be used d. VOCATIONAL/TECHNICAL
NUMBER CERTIFI.__ _ __ _ __ _ __ _Y__ EARS DEGREE fo, "HIGHEST DEGREE" O__ _ _ _ _ __ _ _ _ _ _ F MONTHS CATE REC'C GRADUATE ENGINEERING
fiel) (Use code ob oiMsned.)
TYPE OF TRAINING YES No_ EO EQUIVALENCY
0-NONE_ OTHER: ITE-CERTIFICATE
b. NUMBER OF YEARS 2-ASSOCIATE
OF COLLEGE 3-BACHELOR
4-MASTER B-DOCTORAL
12. TRAINING (AU) 13. EXPERIENCE (AV)a. MONTH AND YEAR b. NUMBER l .MONTH AND YEAR b.NUMBER FROM TO l To FROM TO OM MONTHS 1-NUCLEAR
POWER PLANT FUNDAMENTALS
NAVY sa e sIro o m i I 1 -R 2-PLANT SYSTEMS 2-E2OWlPPWO
CLASSROOM
3-EWS/PPWS
OBSERVATION
4-ERS/CRW 3-OPERATING
PRACTICE B-OTHER (Specify)CONTROL ROOM OPERATIONS
FOSSIL SIMULATOR
OPERATIONS (Includes Classroom)
6-OPERATOR
SIMULATOR
NAMEISS 7-SUPERVISOR
A-PLANT STAFF CERTIFICYES
N 9-OTHER (Specify)N EREC EI D NT U M BE OFN REACLTI N COM M ERCIAL NUCLEA R (including Research/T
esI 4- SRO INSTRUCTION
Reactor)4SOISRCIN
10-REACTOR
OPERATOR-- EXTRA PERSON ON SHIFT 11-SENIOR
OPERATOR 6-REO UALIFICATION
12-SHIFT SUPERVISOR
7-OTHER (Specify)
13-STAFF/SHIFT
ENGINEER 1.4-AUX.IEQUIP. (NONLICENSEDI
OPERATOR 15-PLANT STAFF 16-OTHER (Specify)*-Z --I -I --I-I
-- -.... ~..- -.-..14. EXPERIENCE
DETAILS (AW)a. POSITION TITLE, --, FACILITY c. DUTIES 15. COMMENTS [.pedfy the Ions number to i*hch you aml elaboratrnt)
POW NRC USE I* MEETS; REQUIREMENTS
DOES NOT MEET REQUIREMENTS
15. NRC FOAM 398. CERTIFICATE.
OF MEDICAL EXAMINATION
4AXI ..a. IS ATTACHED bs. WILL BE FORWARDED 17a. I certify'that the Informaiton provldsd.in this foria J& true and correct to the best of my knowledge.
I also authorize the NRC to submit the results of axamlnetlons to my employer for urn in preparing retraining programs.
as: nscessary.,... .. .,.INATU~t
-APPLICANT
I DATE b. I certlf V that the above named individual has or wIll hae" completed by the time of examination all the required training and has learned to operate the controls In a competent and sefe manner pursuant to Title 10. Code of Federal Regulations.
Pert 55; and that the Individual has a need for an Operator/Senior Operator license to perform his/her assigned duties. I also certIfy that the facIllty will be made avallablp.1gr esarnjfelon..
IGAUE-TRAINING
COOROINA~TOR
DT SIGNATURE-
HIGHEST LEVE CORPORATE
MANAGEMENT
DT SIGNATUE DATEFOR PLANT OPERATION
DT c. RENEWAL ONLY.I. certify that the above named Indivdual has satisfactorily completed the approved requalification program as required by section 50.54(1-I)
of 10 CFR 50. and that s/he has discharged hls/hef.Ilcsnsofresprnlob~ltlascompwteftly and safely. ...'4 .*.s -t._ .SIGNATURE
-TRAINING COORDINATOR
_I DATE I SIGNATURE
-~~ MANAUEFAVIT
DATE NRC FPrai9ns~ IV'43I -i,