ML20006D638
| ML20006D638 | |
| Person / Time | |
|---|---|
| Site: | University of Buffalo |
| Issue date: | 01/05/1990 |
| From: | Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Rennie D NEW YORK, STATE UNIV. OF, BUFFALO, NY |
| References | |
| NUDOCS 9002140152 | |
| Download: ML20006D638 (8) | |
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JAN 51990 Docket No:
50-57 g
State University of New York at Buffalo ATTN:
Dr. D. W. Rennie Vice Provost for Research and Graduate Studies Capen Hall Amherst; New York 14260 Gentlemen:
SUBJECT:
REVISED NRC FORMS 396 AND 398 Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualifications Statement - Licensee and revised NRC Form-396 (Enclosure 2),
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 i
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, Origital Signed Er.
P Robert M. Gallo, Chief Operations Branch Division of Reactor Safety w
Enclosures:
As stated
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0FFICIAL RECORD COPY 396 & 398 FORMS - 0053.0.0 12/14/89
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L. G. Henry, Director P. M. Or_losky, Operations Manager M. A. ' Pierro, Radiation Safety Of ficer Dr. William Vernetson, Director of Nuclear Facilities, University of Florida
.Public Document Room (PDR) local Public Document Room (LPDR)
. Nuclear Safety Information Center (NSIC)
State of New. York l
bec w/o enci Region I Docket Room (with concurrences)
Management Assistant, DRMA (w/o enc 1)
C. Cowgill. DRP C. Marschall, SRI - Ginna W. Baunack, DRP D. Haverkamp, DRP 1
OL Facility File DRS:RI Gallo/pb 01/02/9')gg vo f
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OFFICIAL RECORD C9PY 396 & 398 FORMS - 0054.0.0 12/14/89 m
INSTRUCTIONS FOR ODwLETING NRC PORIA MS PSRBONAL QUAllPICATION ST ATOMEttT-LIC68SEE L
TO CEMAIN VALID,TH3 FOR1 MUST NOT BE ALTERED 4.
TYPE OF 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 THAY t'OU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATAON. NOTE: SEE / TEM f4 - THERE IS AN EXCEPTION, ALBO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO *NEW."
2A tlwu 2.e-FOR 2.b THRU 2.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION, NOTE: SEE ITEM f 4 - THERE IS AN EXCEPTION.
2.b RENEWAL
- X"IF YOU ARE RENEWING CURRENT LICENSE.
2.c UPGRADE
- 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 REAPPLYlNG.
s 2.f WAlVER REQUESTED "X"THLAPPLICABLE WAIVER REQUESTED AND JUSTlFY IN COMMENTS SECTION (ITEM 17),
2.s DATE PABBED 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 PASSED, IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE IPWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LED TC TPE ISSUANCE OF A LICENSE. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS, 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 COLLEGE CURRICULUM AND THE HIGHEST DEGREE
- RECElvED, USIN3 THE DEGREE CODE PRO % JED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS CUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, OlESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDI.
TlON AL SPACE IS NEEDED, CONTINUE' UNDER COMMENTS (ITEM 17),
12.
TRAINING ~ INDICATE THE TRAINING YOU HAVE RECElVED TO MEET THE REQUIREMENTS OF ANSI N18,1/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 NUM8ER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED, IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR INTERMITTENT 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 FOH THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13),
1 ALL REQUAllFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REOUALIFICATION ITEM. PLEASE DO NOT " DOUBLE LIST" THE T3ME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, DVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME.
13.
EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE Si1E FOR WHICH THE LICENSE IS SOUGHT IS RtiO'J1 RED, FOR EACH POSITION HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONA1E AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED 1HE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD, 14.
FACILITY OPERATOR TRAINING PROGRAM - INDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PRO AND b. CERTiflED ION NHC FORM 474) OR NRC APPROVED SIMULATION FACILITY is USED IN THE OPERATOR TRAINING PRO.
(
GRAM, IF "YES" IS CHECKED IN BOTH ITEMS 14.s AND 14.b THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),
i AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTEO, l'EW APPLICATIONS MUST STILL INCLUDE THE NUMBER L
OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION SY THE l
NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1Ji, REV,2. ARE MET, 16.
FOR RENEWALS ONLY - (1) ENTER THE APPROXlMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENS3 IF HRST RENEWAL, (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION EXAMI-l NATION.
L 18, 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 (lTEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATION, 17 COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE AP CATION FORM. IF THE SPACE PROVIDED is NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.
T!ON, 18 NRC FORM 398, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THl$ APPLICATION.
it.
SIGNATURF% - SIGN AND DATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SE MANAGEMENT REPRESENTATIVE ON SITE.
CETACH THESE INSTRUCTIONii AND SUSMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EAC6f)
PRIATE REGIONAL ADMINISTRATOR.
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tb I senHy unter psammy et gestury the the intermesson in this sessumeen end erseteunents is teve and servest. I further sevisty that 4 home notifaud my oursent emp6 eyer of. lt) eel postous engstoyees.
- (M en, ennense shore a have anon esmed by e HasMn and Human Sernssa IMHBI Certthed Drue Temens Lahosesory or e Licensse's temene tscHny for eleshel er e contre.ksp subsense. end les ten J puesuene so to CPR Port 20:IM env enmense seheee i s ue usan enemed ter the esse, use er seismen et e eenirehad m ase asumthed en to CPR Part 26;
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... e CERTIFICATION OF MEDlCAL EXAMINATION qqo,,,c,Tayj,,"Aago;ggg,y,g BY v e'%pe UCgSg
.maleCM se.30l= USDC atibt. aft WJCLi
- lGuLATOmv Coastest ga ee llOh ha&McNGTOh aluD 70 THE earsmimonet M OUCTIO4 ##0Jf CT (29to4EC46 Oeeeet Oe 4s444.38 wikT AND SvDGl? massumGTON DC poto2 NAME OF APPLic. ANT F ACILITy lF ACILITY DOCeLET NUtssE R A. MEDICAL EXANIINATION CIRTIFICATION THIS IS TO CE R TIF V THAT THE ABOVE N AMED APPLICANT FOR AN OPER ATOR SENIOR OPE R ATOR LICENSE M AS BEEN E k AMINED BY A PHYSICIAN PRIN TED N AME fotonysaceant lbT ATE AND LICENSE NUMttR E Kr.MINATON D ATE I
B ASED ON THE RE SULTS OF YHE E AAMIN ATION INCLUDING INFORMATION FURNISHED 6v THE APPLICANT. THE PHYSICsAN HAS DETERMINED TH AT THE APPLICANT'S PHYSICAL CONDITION AND GELE R AL HE ALTH ARE NOT SUCH THAT ti MIGHT CAUSE OPER ATIO LIC HE ALTH AND SAF ETY l CE RTIF V THAT IN DE ACHING THis DETE RMINAisON THE GutD ANCE CONT AINED IN ANSI /ANS 3 41983. OR ANSI, ANS 15 4 t977 FOLLOWED ANN THAT DOCUMENTAf TON is AVAILABLE FOR REVIEW BY NRC.
i ON THE BASIE W
- AE RECOMMENDATl'JN OF Tid.fHYSICIAN I RECOMMEND fMAT THE APPLICANT *S OPER ATOR LICEN3E SE CONDITIONED AS FOLLOWS.
- t. NO RESTRIC180NS
- 2. CORRECTIVE LENSES DE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HE ARING AlD BE WORN WHEN PERFORMING LICENSED DUTIES l
4 R(ST RICTED LICE NSE OR E xCEPTION. Provide setails twoow and attach supportmo medicai evidence toe NFic revie.
S AE STRfCTION CHANGE F ROM PRE VIOUS SUBMITT AL Piovce deiads twoon and attach supserime medical ovmence for NRC #evew PROPOSE D WORDING OF RESTRICTION (8seva e saover 1
LE LATIONSHIP OF R EST RICTION TO OtSOUALIF YING CONDITION (sieetir eridscare 40. restreeten eiv#1corsect the casouewynne conrintens KEMARKS FOR R E STRICTION CHANGE (8auca 5 abover l
B. NONMLDICAL CERilfICAllON POWER RE ACTORS THis CERTIF sES THAT THE APPLICANT HAS SEEN FOUND TO ME ET THE SAFEGUARDS' AND FITNESS FOR DUTY REQUIRECEN*S OF THis F APtLITY FOR LICENSED OPER ATOR$.
NON POWE R RE ACTORS.
THIS CERTIFiE% THAT THE A so.lCANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' R81UIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS. AND 6 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SusST ANCES AS ESTABL*SHEU PURSUANT TO 10 CF R 76 Nv s atst sta ttuent on owmaium m taes occvuemt isctuoma at tacmsmis was se susanci ro civit amo omimiha6 6ametivms,i ctut a v umush rtha6: e ut IlmJun v iwat tot impommatsois am ruis poCVMENT aNo aTT ACHMENTS it Ymut AND COmmtCT.
PRINTED N AME AND $4GN ATURE (. San,or asenseement Nepressnestsee on S,rei TITLE DATE in acco#cance witn to CF R bl.6, Communications, this term snail be suomitted to ;ne NRC as toisows a y MAIL ADDRESSED TO:
Regenal Admeantrator. Region i Regenal Admmistrator. Regen 41 Regional A Hainmrator Region all U 1 %ctear Regulatorv Commission U S. Nucmar Rewtatorv Cornmision U S Noctear Reeplatory Comminen 476 Aliancate Road 101 Marieria Street. Suite 3100 799 Roowvest Road Emq of Pruu a. P A 19406 Atlanta GA 30373 Gwn Ellyn IL 60137 Regenal Administrator. Region IV Regenat Aammatraior. Region V U S. Ncisar Regulatory Commision U S. Nuclear Regulatory Commissen 411 Ryan Plus Onve, Suite 4000 1450 Mew Lane. Suite 210 Actington. T x 76011 Wamut Creek. CA 9496 PRiv ACy ACT ST AT EMEN T Puisuant to S U.S C 55?Me:(31. eriseted mto tan Dv weten 3 of IN Pmacy Act of ROUTINE USES The mtormation may tie drsclosed to en approcrete Feoeral. St.te or 1974 IPublic La* 93 579L the Iowawm3 stateme" is 'umaned to inc' viduais who locai agency in the event the information moscaies a eiosaien or potential veiaten of law supoiv informaten to the US Nuciaar Regulatory Commessen on NRC Form 396. and m the event the moormation moscates a vioisten or notentisi viosaten of law and m Thn informaten a maintama$ in a system of records designated as NRC l', and the course of an administrative oe pudicial proceedme in addition. th.s mformaten may be desentmt at bt Fawral Regisier 33157 (Septemter 18.19861 transterved to en appropriate Federai. State. and locat agency to the entent reievent and AUTHORITY Sec ent 107 and 1611.) of the Atomic Energy Act of 1954, as noceuary for an NRC decision sbout you.
amenced t42 V S C. 2137 snd 7701Mt.
WHETHER DISCLOSURE 15 MANDATORY OR v0LUNTARY AND EFFECT ON PRINCIP AL PURPOSE (SF Information entered on the form *s und to determme INDIVIDUAL CF NOT PROviDING INFORMATION Disclosure a voiuntary. If the ahether the phyvcal conditen and general he?lth of the apphcant are such that they requested mtormation is not provided. however, the oppsication for a facility oot'rator i edi ret caun oceratione erron ennengermg putmc twaith and sa'eiv.1ha moorma-or uner operator s ucenu may oe cened ten may be uno Dv % NRC stal' to determine is the individuai meen the requi'e SYSTEM MANACFRIS) AND ADDRESb. Chiet Owaior Licenung Branch. OHice of monts of 10 CF R 55 to taae an euminsten or to tw issued an operato# s license
%cieer Peactor Reguisten. Ufe a meer Regwatory Comminen. Wahingioi DC 20555 Nuc eqege Saam on age
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IN3DGURE 3 STAtlARY OF QWGES 10 MIC FORf 596 Medical Examination Certificat1m Added block "Bestriction Change From Prwicus Submittal" plus Banarks emotion.
HanWir=1 Certification Changed non-==diaal certification statauant to: Peuer Reacrtore-this certifies that the applicartt has been found to meet the maf=s-tis' and fih for & sty reguirementa of this 1
this facility for licensed operatore.
hThis certifies that the appliennt has been found to aset the safesuartis' requirements of this facility for 14a====d operatore a d I have no knowledge of the applicant
==a== ding the curtoff levels for alochol or controlled substances as es+mh14=had pursuant to 10 CFR 26.
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DICIASURE 4 i
t SCRetARY OF OIAttEE 10 lE FCIM 398 Item 4.d Added clarifying statement to indiasta this is to be checked caly if appliostian is to amend license to add additional unit (s).
Item 4.f Added "(Category)" to operating.
Add _ed " Medical".
i Item 4.s Added a new item "Date Panned Generic Fundamentals 1
h=mwtion Sectian",
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Item 12.3 Changed wording to " Certified Startup Presrom Completed" for clarificatiau.
Item 12.5 Channed wording to "hetra Pesson On Shift In Control Room t
(13-week minim a)" for clarification.
Item 12.5a Added a now item " Time On Rd.ft Above 205 Peuer (6 Seek minima)".
Item 14.a Added the words "1 hat Is Bened Upon A Systems Approach to Training" for clarification.
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Item 15 Added "Date and Result of Host Recent IRC Administered l
lleeutlificatica Enemination".
Item 19.a Added the wording "I Aarther certifF that I have notified.
er current employer of: (1) all.pewicus employers (2) any instance where I have been tested by a Health and H aan Services (MB) Certified Ikus Testing Laboestory or a Licensee's testing facility for alochol or a controlled eubstanos, and the test results =w the autoff levels established pursuant to 10 CFR Part 26; (3) any instance where I have been arrested for the sale, use or peesession of a controlled substamos desoribed in 10 CFR Part 26; and.
(4) any reasons for removal or revocation of unescorted aooses at a nuclear facility".
L Item 19.b and l'/
Item 19.c Moved 19.b and 19.c tesother. Asplicable box aust now be checked. Also added block for typed name of Tr=4aian Coordinator and Anniar Manap====t Representative On Site.
FOR NRC USE thder waiver cetesary addad " Medical".
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