ML20006D644

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

ML20006D644
Person / Time
Site:	Rensselaer Polytechnic Institute
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Block R RENSSELAER POLYTECHNIC INSTITUTE, TROY, NY
References
NUDOCS 9002140160
Download: ML20006D644 (8)

Text

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-c cf JAN 5 1990 i

Docke No: 50-225

{

Rensselaer Polytechnic Institute _

[

ATTN: Dr. Robert C. Block, Chairman Department of Nuclear Engineering and Engineer Physics NES 1-9 Troy, New-York 12180-3590 i

Gentlemen:

[

SUBJECT:

REVISED NRC FORMS 396 AND 398 Enclosed is a copy of the -evised HRC 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 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, Original Signed Byt' Robert M. Gallo, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated

[

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m 9002140160 900105 DR ADOCK 0500 5

0FFICIAL RECORD COPY 396 & 398 FORMS - 0049.0.0 12/14/89

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s Rensselaer Polytechnic Institute 2

cc w/ enc 1:

Dr. D.-R. Harris, Director, Reactor Critical Facility (RCF)

P.-Angelo, Supervisor, RCF Dr. G. Judd, Vice Provost, Dean of Graduate: School 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 I

bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

D. Havetkamp,'DRP J. Macdonald, SRI - Yankee Rowe L. Doerflein. DRP

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01/02/9 t

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OFFICIAL RECORD COPY 396 & 398 FORMS - 0050.0.0 12/14/89

1886TRUCTIONS FOR 00MPL ETING NRC PORM EBB s

PERBONAL OUALIFICATiON 8TATEMENT-LICENSEE TO GEMAIN VALID,THis FORM MUST NOT BE ALTEZED i

4 TYPE OF' APPLICATION 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 YO'l HAVE i

RECEIVED UP TO THE DATE OF THl3 APPLICAT40N. NOTE: SEE ITEM I4 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "N EW.*

2.b thrv 2.e-FOR 2.b THRU 2.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION. NOTE: SEE / TEM 74 - THERE IS AN l

E XCEl' TION.

l 24 RENEWAL

• X"lF YOU ARE RENEWING CURRENT LICENSE.

2.s UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, i

2d MULTl UNIT ~ X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR.

HENT LICENSE TO ADD AN ADDITIONAL UNIT, 2.e REAPPLICATION "X"1F YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

i 2.1 WAlVER REQUESTED

X"THE. APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

2.g DATE PAB8ED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES).

THl6 IS NOT APPLICABLE TO RESEARCH 9EACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.

TION SECTION OF THE WRITTEN EXAMIN ATION 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 CF A LICENSE. THIS DOES NOT LNCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXA MIN ATIONS.

11, EDUCATIDN - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR M ARE A(S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRif ULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PHOVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR COND'TIONING/ REFRIGERATION, blESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDl-TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17).

12.

TRAINING - INDICATE THE TRAINING YOU HAVE PECEIVED TO MEET THE REQUIREMENTS OF ANSt N18.1/ANS 3.1. T BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS, REFER TO THE STANDARDS IF YOU NEED

- FURTHER CLARlFICATION INCL,UDE BOTH FfGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNPNG AND COMPLETION DATES.

TO ACCOUNT FOR INTERMITTENT TRAINING (FOR EXAMPLE,4 WEEK 3 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 APPLIED FOR CANdOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13),

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOn IN THE REQUAllFICATION ITEM FLEASE DO NO LIST" THE TIME SPLNT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLAS3 ROOM OR SIMULATOR TIME.

13.

EXFFhlENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS ROUGHT IS REQUIRED. FOR EAC llELD. COMPLETE ITEM 16. DO NOT DOVBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERli ASStGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOU NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEEO THE NUMBER OF MONTHS THAT ARE IN TIME PERIOD, FACILITt DPERATOR TRAlhlWG PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRA 14 AND k STiFKO 'S! W TO*M '70 ON NNC APPROVED SIMULATION f ACILITY IS USED IN THE OPERATOR TRAINING PRO-GRAM. IF "YJS" IS CHECKED IN Al)TH ITEMS 144 AND 14.t), THEN ITEMS 11 (EDUCATION),1C (TRAINING),13 (EXPERIENCE 1, AND 16 (E%PERIENCE D' ETAILS) Dr) N(W HAVE TO BE DOCUMENTED. NEW APPLICATIONS MUST STILL INCLUDE THE NU OF SIGNIFICANT CONTHOL MANIPULATONS UNDER ITEM 12.3, NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAS NUCO AM ACCREDi~ LNG BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATO GUIDE 1.0, REV,2, ARE MET.

FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANC 15 LICENSE 3F Fl'IST RENEWAL. (2) ENTER DAIG AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION NATION.

'll

. EAPERIENCE D0 TAILS - INCLUDE POSITIO4 TITLE, TIME PERIOD-FROM/TO. FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT PO$lTiON, IF MORE SPACE IS NEEDED, USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH AVE'IT!ONAL1MORMATV)N.

M.

COMMENTS - USE T*S SPAct TO L%CLUr'E ANY EXTRA INFORMATION OR CLARlFICATION FOR OTHER ITEMS ON TH CATION FORM. lF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA-TION.

, l8.

NRC FORM 398, CERTIFICATION OF HEDICAL EXAMINATION BY F ACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

19.

SIGNATURES - slGN AND DAW.1 TEM 19.a. ODTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR S MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUSMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH PRIATE REGIONAL ADMINIRTRATOR.

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l _6 poesTeDes TITLE PROW 10 es f actLITY 16 DUTees p l-4 l: ? ) t. ? ? a: 1 ? P l st,poseAswTS as % e nemm, et e roee.. . A,-i.eemance e== = as--s,r.s f l 6 18, AIRC PORip 308. CERTIFICATION OP llAEDICAL EKAAAINAf tDN SY P ACILITV LICENSEE,18 ATTACHt0 ANY f ALSE STAT 3 MENT OR OMittlON IN THIS DOCUMENT, INCLUDING ATT ACHMENTS, MAY BE SUGJECT TO CIVIL AND CRlWiNAL SANCTIONS. m o aer Hy sneer sene.hy et pernwy thei the inearavisalon in shle daeument estri ettethments is Ifwe end sortset. I furth eerlih thet i Beve flottheit my ourcesel engbleyer of, lit est ( Tweous enqployerg; T tal any enseense we no I how men iemed eiv e Hometh end Human servtsee (HMS,I Cent 6 feed Drug Testeng Laterefory et a temenese's teett'iS lordity Sne ettetyst et e cont # tilled edere f savne onesened the evien news emewished perwom so to CP R Peri To. m en enseence wasee I have amen arvened ter the esseune er posesuma et e e mrohed summene doisvend in 10 Ce n Pe t te. esef $45 eny fuerne tot feMonsi Jr revocetItm of efieuerted essene et a misteerilecility,4 eeen authertse the $ DMO qe outWhat the eengist of etenerseigne to nyy orngmyers lor pee en eseptring regremine pestseens. a sessmery EfURL-APPL 8CAest Datt CHOCK APPUCASLE DOX b, i eeneh,em cet ie e neesi md.ewshal he weseege ny monted the escuny ucernen esauw menis en to hsensed m en opeu enin'io.e one.,m.er ow m I eem uw ein u e J Ni es sw ndosi h e new ser en c.. c 1 o m-r ucer= is pern-m he=r an.or d dei = ene: iw ine is .a i n as ese.une en m e

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4 Rt ST RICTE D L8CE NSE Of' E MCIPTION P'o use esta fi tolen and sitsh suomwimg medical esinence for NRC rev.ew ~mmere 6 At LT RICTION CHANGE F ROM PRt VIOUS $UBMITT AL Piove, netaets twine etwa attoch supportmo mecae evitteau 'or NRC ee.see Pl.OPoht D WORDING OF RE STRICTION #8tma 4 steves it LAllON5 HIP OF RESTRICTION TO DISOUALIF YING CONDtT ION IS,wny messere now restraten well rorrm1 the assesueter ene mmrerent r F;l MARKS FOR R($1RICTION CH ANGE (8/oca 3 aticies ti. NONMLDIC AL C& HilF ICA lion POWE R Rt ACTOR $ TH15 CE Ril6 6t$ THAT THE APPLICANT HAS BL EN FOUND TO Miti THE SAf tGUARDS' AND FIT't tLS FOR JUf Y REOUIREM(NTS OF THIS F ActLIT Y FOR LICEN5tD opt RATORE NON POWE R RE ACTOR $ THl$ CERilfit$ THAT THE APPLICANT HA':8ttN FOUND TO Mitt THE $AFIGUARDS' REQUIRE Mt NTS OF THt1 F ACillTY FOR LICEN$tD OPERATORS AND 4 HAVE NO ANOWLEDGE OF THE APPLICANT EXCitDING THE CUTOF f LivtLS FOR ALCOHOL OR CONT ROLLED SUPST ANCES A5 (51 ABLISHE D PUR$UANT TO 10 CF R 76 9 .NL t uptNt a f f At resi' Nia w A y 6e topJ64 t Iw (sv et ANu LHawiNA L aANs I suNn i 4iM t to = UNug es rg nag l, we f.NV P aLat a f A f 6 Mtht UM uMoutu% in twig Dut uut N f s it AJURV IHA T THE serOMMattok 14 THi$ DOCUMt NI AND &t'l ACHMt ht$ il1RVE AND CQhn$Ci. PalNIE D NAME AND SIGN AI URL (Sertsor 4fanairemerit Represorttersie 03:5,res TIf LL Dalt in uccenarwe enh to CF M 66 6 Commumtaisuni this form sheti be womittee to the NRC as totsces. g y Mall ADDRL55tp iO Regenas Avmimstrator Reg.on i Regenet Admmistrator. Reg un il Regione. Admin 4tratos Regen til U St Noctur Roguestory Comminuon U S. Nuclear Regutaiosv Comminien U $ Nuour Neewiaior, Commauon oft Allendaio Road 101 Maretta Si#eet. Suete 3100 799 Roowvest hoad Gen iu a, II, 40137 King of Pruu a PA 19406 Atlanta GA 30323 v Regional Admemit#4taf. Region tv Regeties Administrator Region V U 5. Nucine Ra,uietary Commaien U S Nuccese Requistory Commaien 611 Ryan Ptana Drew kne 1000 1450 Maria Lane. Lite 210 Artir.gton. IX 7601i Wamut Ceen. C % 94b96 PRiv ACY ACI bf Af t ME NT Pursuant to 6 U $ C 6524tell31. enuted mio ian by wet.on 3 of the Privacy Act of ROUTINE U$t S The mio<mation mov be aeman to en accropriaie hieras. stave. or local agenry m the event ;he mo rmaten ireicates e v.oistice or patentist veoisten of iem l 1974 IPublic La* 93 6191 the tonoemg statement it 'ummhast to mnividuati who o supply mbematen to the U S Nucisar Reguistoey Commision on NRC Fo<m 396 anet m the event the informaten semicates a,eween os mmnt.ar einie en of law ano m This into<mation is mamtemed m a evitem et eci>rdi designated as tiRC 16 and the course of an sammatrai ve oe ludiciai procadmg in monaion. i.i mlormaien may be h descritwd at 61 F edeial Reg.iier 33157 (Septemtet 18,19861 teanitevred to an app 6epr. ate F ede'ai Siate. ann locas spacy to the estent vese=ent anu AUTHOltlTY Sections 107 and 16H ) of the Atomic Eneigv Act o 1954 as necesia'v tot an NRC oecmun steut you s amenned id? U S C 21314md 22011.li ht f ME R DISCLOSURE 'S V ANDATORY OR VUtuNTARY ANO E8FECT ON PRINCIP AL PURPOSI($L fnlotmeten entered on thin 4rm a used to neiermm, AOlviDUAL OF NOT PROviDING INFORMAfiON Dwasu e.i voiuntar y. H 'he e whethet the physical cond;Iin antl generas health of the applicant are such tha. thev +3ueM mbfmaten a W pwM fe*ew W appWaten W e WitV oWaW i Wi1 riot Eause opFf ational ettofi efeangermg pubhc health and safety 1 ha informa-O' senet opetaf or i license may ( e uen40 tion Hiay be Usen Dv tte NNC ltoff to dettemme of he mdgedual muti the purguire $Y$Tt M MANAGE R{$) AND ADDRE U CNef Owstor uermng Branch OHice of t ( ments of 10 CF R 56 to teu en esaminaten or to be invad an operatoe a tecerne Nucient Postot Requiaien. U $ Nucwas Regu.atory Girhmouun WanNngios DC 20556 L weenev w mae 4 i I INCIASURE 3 i SGtWE OF OWGS '!O Mic Falm 396 i Medical Examinatien Certification Mded blamit " Restriction Change From - Prwious Sukunittal" plus Ramants sectim. 1 Non-Medical Certificatim Changed non endical certification I statement to: Ptnser Reactors-This oortifies that the applicant has been found to meet the safasuards' and fitmees for thaty repuirements of this this facility for licensed operators. Nonpomer-This certifies that the applicant has been found to meet the safeguards' rsquirements of this l facility for licensed operstors and I have no knowledge of the appliosat exoseding the autoff 1svols for alanhal J l or controlled substances as es*=h14=had l pursuant to 10 CFR 26. r. t h t t 4 g-,m...., _.,.., .m.,, .._,..m., m ..#.m -- m ?- n Dt2000FX 4 i Suttwet 0F QWass 'to 15C WOIH 396 Item 4.d Added clarifying statement to indioste this is to be checked only if applicatian is to amend license to add additional unit (s). I Item 4.f - Added "(Catasorr)" to Operating. Added " Medical". Item 4.s Added a new item "Date Passed Generic Fundsmantals t= amination Section". Itan 12.3 s Changed wortiing to " Certified Startup Program Completed" l for clarificatim. Item 12.5 Changed wording to " Extra Person On Shift In Control Room (13-week min 4==)" for clarifiestian. Item 12.5a Added a new item " Time on 8tdtt Above 205 Peuer (6-week minima)". i Itam 14.a Added the words "That Is Based Upon A Systeen Asproach to '"r= 4 a i a=" for clarification. Itam 15 i Added "Date and Result of Most Roosnt NRC Administered Depaalificatie Eneminatica". Item 19.a Added the wording "I Aarther certify that I have notified. or oe.rrent employer of: (1) all prwious employers (2) any instance where I have been tested by a Health and Ikaan Services (HBB) Certified Dnar Testing Laborotory or a Licensee's testing facility for alanhal or a centrolled substance, and the test resulta es,oseded the autoff levels established parouant to 10 CFR Part 26: (3) any instance where I have been arrested for the aale, use or possession of a controlled substance described in 10 CFR Part 26 and (4) any reasons for removal or revocation of unescorted econse at a nuclear facility". Item 19.b and Item 19.c Moved 19.b and 19.c teerther. Applicable box aust now be checked. Also added block for typed name of Training Coordinator and Anniar Management b a tetive On Site. 70R HRC USE thder waiver ostesary added " Medical". l l I .',- ;.... - -,, - -. - - - ~ - + - - - - - - - - - - - - - - - ~ ~ ~ ' ^ - - - - ~ ^ ^~ ~ ~ ~ ~ ~ ~'