ML19326C968

Forwards J Robertson Medical Examination Rept for AEC Medical Consultant Comments Re Licensing Eligibility

ML19326C968
Person / Time
Site:	Arkansas Nuclear
Issue date:	05/14/1970
From:	Cavanaugh W ARKANSAS POWER & LIGHT CO.
To:	Birkel R US ATOMIC ENERGY COMMISSION (AEC)
References
NUDOCS 8004290597
Download: ML19326C968 (5)

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H E L PIN G GUILO A ft K A N S A S ARK ANS AS POWER S LIGHT COMPANY STH G LOUISf AN A GTAEETS . LITTLE ACCK. ARK ANSAS 72203 1501)372 4311 May 14, 1970 .

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Atomic Energy Comission

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4915 St. Elmo #. venue ffy,.y;.4-Bethesda, Maryland 21811 _-_

Attention: Mr. Ralph Birkel, Project Engineer Division of Reactor Licensing

SUBJECT:

ARKANSAS NUCLEAR ONE FERSONNEL POOR QUAUTY PAGES FILE: 0400

Dear Mr. Birkel:

Enclosed is the Medical Examination Report for Mr. Jack Robertson which you and I discussed in our telephone conversation today.

I would appreciate your doctor's review of this report and what-ever coments he might have regarding this ran's eligibility for licensing.

Very truly yours,

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William Cavanaugh Assistant Superintendent ARKANSAS UUCLEAR ONE WC:aw Enclosure T AX P AYING. INVE S TO A OWNED MEMBE A MlOOLE SOUTH UTILITIES SYSTEM 8004290 577 (/

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Form Age ate

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(949) Buessu or Budget No. 38.R0s4 to era ss ATOMIC ENERGY COMMISSION CERTIFICATE OF MEDICAL HISTORY Facility Operator's or Senior Operator's License tietructions: Applicant must complete all items on page 1. Typewrite or print in ink Physician must complete all items on page 2.

1.LastName First Name Middle Name 2. Date Birth k $$'?Y SeN $4 Q.stf. ~

/$ .8/h? N

3. Home Address 4. Se7 YOO Wl4s $.5 S't" hl=. l ~r"y'L/I C$ Nb3 b % E3' $ -

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Have you ever had or do you now have any of the following? Give details of any condition answered in the affirmative under item 38. *

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y., N. ~ v.. No S. Rheumatic fever l l Y 18. Bone, joint. or other defer-ity I I

6. Frequent or severe headaches  ! Y 17. Painful or " trick" shoulder i I X

7. Dizziness or fainting spells V i 18. Painfal er " trick" elbow l T

8. Eye trouble )( 19. Paralysis Y

9. Diabetes )( 20. Epilepsy cr fits X

10. Tuberculosis 'Y 21. Depression or excessive wt.Ty N

11. Chronic shortness of breath X 22. Loss of memory or amnesia i iV

12. Pain or pressure in chest or " heart attack" Y 23. Nervous condition which could impair

13. I fgh blood pressure Ti judgment or reliability y

14. Low blood pressure M i 24. Drug or nr.rectic habit 1 i Y

15. Pertie ulcer i ' X' i 25. Excessive drinking habit I IT Complete each of the following. Give details of every affirmative answer under item 37 .

Yes No

26. Has your work ever been limited or restricted for medical reasons)

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27. Have you ever been denied or rated up for life insurance for medical reasons) X

28. Have you ever been under cbservation or received care or treatment for any mectal or nervous condition as a patient in a hospital, satutorium, clinic, or other facility. or from a physician, ci!nical psychologist, etc.? I7

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29. Have you ever been rejected for or dischvged from employment or military service for physical. mental, or nervous disorder reasons? ,

30. Have you ever received. is there pending. have you applied for. or do you intend to apply for pension or compensation for existing disability?

31. Have you ever seriously considered committing suicide $

X l i N'

32. Have you ever been convicted of any violation of Federal law. State law. county or municipal law. regulations or ordinance? Do not include anything that happened before your 16th birthday. Do not include violations for which a fine of $25 or less was imposed.

33. Have you ever had any major illness or injury otter than those already noted?

34. How many jobs have you had in the last 3 years' l 'k

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35. What is the length of time in your ;tesent employment?

36. Give a brief statement of your present health in your own words:

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37. Details of any items 5 throuan 33 answered in the affirmative. In addition. if yetr medical nistory includes any matter relating to physical, mental, or nervo'us condition, please describe the condit:en and set forth your explanation of why this matte would not Q.}affect Q(tgyour & ability Ak 4,to6N*dS~ZA function as a facility :.perarar. Use acditional sheet g[f more space is needed.

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N ulh)l lEC'7' En s O b 4 W r* C h "D l w $ l k . $ ; & # el l & /W '

38. I certify that the foregoing intermation supplied by =e is true to the best of my k::owledge, and authorize the Atomic Energyrom-mission to usc any of the infermation :n t".is certificate in tne exercise of its authct:ty over the licensing of cperatcts.

DC WAb ; 4A'2 W (Date) (rectit:y) (s.sriaew or .ppste.n:)

SIGN YOl'R NAME IN INK AS IT APPEARS ON YOt;R APPLICATION FOR OPERATOR'S OR SENIOR OPERATOR *S LICENSE i

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MEDICAL EXAMINATION

39. Coctees it is creenti:1 that.ooch of the items on this pog3 be compl:t;d. Sign th3 Czetitixots and mill to the Director, Divlslon ci Reectee 1.lconsing, United States Atomic Energy Commission, Washington, D.C. 20545 for reactor operator license opplicants et to the Director, Division of Moreelots Licensing, United Stoves Atomic Enstgy Commission, Washington, D.C. 20545 for oppit.

centsifer_nen-eooctee operator licenses.

. - 40. Physicisess's Svamoey and elaboration of the medical history on front of report. Use additional sheet if more space is needed.

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- Ml' Ny P4psical Examtmation. Give details of abnormal findings under item 21 below.

1. Date of examination

4. Blood pressure f // p 2. Helght f /0 3 **18ht /2 /

)//0 fed 5. Pulse 91

6. Distant visual acuity uncorrected right d left .oO method used a ,

'7. Distant visual aculty currected right # 1 eft ec (data required only if corrective lenses are normally worm

8. Near visual aculty uncorrected right gj left ,7 // method used pg._ _

'9. Near visual acuity corrected right ,f / left J~// (data required only if correctNe lenses are no = ally werm

'10. Color vision , method used

\11. Gross visual !!alds -

12. Hearing M( right b left method used , . p

13. Eyes, general *

, 14. Pupils ft.-[ dr((, - J2g ph a 6%L

15. Ophthalmoscepic /d f &/f __ M 2 e f4 hw \_ M 4 % % m id , d i

16. Ects. general SLR /

i7. Drums C% d

18. Heart y/C ,

,19. Vascular system @(

20. Date and evaluation of chest 2-ray taken within the past year, kQ.

21. Details and evaluation of any item 1 through 20. above. reported ab ormal and summary evaluation of oxetall con.dition.

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22. Tha feregoing examination (donadoes act) reveal any mental or physical disability which might cause impaired judgment or motor coordination.

1 understand that any of the information in this examinition may b used b the Atomic dergNo . mission in the exercise of its

, authority over the licensing of operate's. , ,/ l M7d (Dete)

/ p (signature of esarnansas payssetan) N N n (- f" Typed of ' printed name of enemsning pnyttenen DOCTOR: IT 15 REQUIRED Nd) /d< 0,0 l

THAT EVERY ITEM ON THIS PAGE BE COMPLETED EX-

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CEPT THOSE MARKED WITH

• WHEN NOT APPLICABLE.

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ARKANSAS POWER & LIGHT COMPANY l3 ,arte n A 6~ 7 psa r/ h .

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. L ATOMIC ENERGY COMMISSION j

\.J ATTENTION: MR. RALPli BIRKEL, 4915 ST. ELMO AVENUE '

PROJECT ENGINEER ,

DIVISION OF REACTOR LICENSING BETIIESDA, MARYIRID 21811

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Sa ** * *""'a- Fw ca' 'a**- '"*"'*a-irr. Arc-93 :Rev. May 14,1947) AssA 0240 Note and rett For sig re. For Information.

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bM" USE OTMEA SIDE FOR ADDITIONAL REM' ASS bh CPO e 1971 's - 445-463 1