ML20006D645
| ML20006D645 | |
| Person / Time | |
|---|---|
| Site: | MIT Nuclear Research Reactor |
| Issue date: | 01/05/1990 |
| From: | Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Bernard J MASSACHUSETTS INSTITUTE OF TECHNOLOGY, CAMBRIDGE |
| References | |
| NUDOCS 9002140164 | |
| Download: ML20006D645 (8) | |
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.lau 5 1990 F
L Docket No:
50-20 i
Massachusetts Institute of Technology Research Reactor ATTN: Dr. John A. Bernard, Jr.
Director of Reactor Operations 138 Albany Street Cambridge, Massachusetts 02139 Gentlemen:
SUBJECT:
REVISED NRC FORMS'396 AND 398 i
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 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.
Conteat(215)337-5120 or Peter W. Eselgroth at (215) 337-5211.
Sincerely, crighel 5Hned M 7
l Robert M. Gallo, Chief Operations Branch Division of Reactor Safety
Enclosures:
As stated j
9002140164 900103 f t PDR ADOCK 05000020 ki
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r OFFICIAL RECORD COPY 396 & 398 FORM 5 - 0047.0.0 12/14/89
' Massadhusetts Institute of 2
Technology Research Reactor cc w/ enc 1:
Dr. O. K. Harling, Director of the Reactor Laboratory K. S. Kwok, Superintendent of Reactor Operations Dr. William Vernetson,' Director of Nuclear Facilities, University of Florida
- L Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
Commonwealth of Massachusetts (2) bec w/o enc 1:
Region I Docket Room (with concurrences)
Management Assistant, DRMA (w/o enc 1)
D. Haverkamp. DRP R. Blough, DRP J. Lyash, DRP C. Warren, SRI - Pilgrim OL Facility File DRS:RI Gallo/pb h 01/02/9 cf v
4 OFFICIAL RECORD COPY 396 & 398 FORMS - 0048.0.0 12/14/89 m
m.
i INSTRUCTlONS FOR COMPLETING NRC PORM 358 I
- t RBONAL OUALIFICATION ST Af tMEltT-LICENBE E TO CEMAIN VALID,TH'] FORM MUST NOT BE ALTERED
- 4 1YPE OF APPLlCAT60N 2.e NEW
,"X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW, THC IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE i
RECEIVED UP TO THE DATL OF THit APPLICATAON. NOTE: SEE / TEM 14 - THErsE IS AN EXCEPTION, ALSO, THis i
BLOCK IS TO BE MARKED l> PREVIOUS NEW APPLICATION WAS WITHDRAWN, PL8.ASE WRITE " WITHDREW" NEXT i
TO N E W."
2A thm 2.s-FOR 2b THRU 2.e. COMPLETE EACH CATEGORY COMPLETELY,IdT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION. NOTE: SEE / TEM 14 - THERE sS AN i
E XCEPTION.
2A RENEWAL "X"(F YOU ARE RENEWING CURRENT LICENSE, 2.c UPGRADE "XIF YOU HOLD A RO LICENSE AND ARE NOW APPLYlNG TO UPGRADE YOUR LICENSE TO A SRO, 2.d MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG TO AMEND YOUR CUR.
RENT LICENSE TO ADO AN ADDITIONAL UNIT, 2.e RE APPLICATION = "X"lF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND AHE REAPPLYING, 2.f WAIVER REOUESTED "X"THLAPPLICABLE WAlVER StEOUESTED AND JUSTIFY iN COMMENTS SECTION (ITEM 17).
2.s DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES).
THIS 18 NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.
TION SECTION OF THE WRITTEN EXAMINATION WAS PASSED IF THE GFESWAS NOT TAKEN,YOU MU$f HAVE PASSED AN NRC LIC$NSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LED TO THE ISSUANCE OF A LICENSE, THis DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION
)
EXAMINATIONS.
11.
EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAldTECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREAIS) OF STUDY, INDICATE THE HUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED, FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE 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 DEGREEWAS AWARDED, IF ADDl.
TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17),
j 12.
TRAINING - !NDICATE 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 NUMBER OF WEEKS SPENT 1t4 EACH 1YPE 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 W SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UND EXPERIENCE (ITEM 13),
ALL REOUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REOUAllFICATION ITEM, PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REOVAllFICATION TRAINING UNDER ITEM 12.0, REOUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME, 13, EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REOUIRED, FOR EACH POSITION HELO. COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES.THE MONTHS SHOULC' REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD l
NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN TH TIME PERIOD, 14, FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROG "F!ED (ON NRC FORM 474) OR NRC APPROVED SIMULATlUm mwi e as vacu m a nt UrtNMlOH lHAINING PRO.
GRAM. IF "YES" l$ CHECKED IN BOTH ITEMS 144 AND 14.b THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),
AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED, NEW APPLICATIONS MUST STILL INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY TH NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REOUIREMENTS OF REGULATOR GUIDE 1,8, REV,2, ARE MET, 15, FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANC LICENSE IF FIRST RENEWAL, (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REOUALIFICATION EXAMI.
I N ATION.
I 16.
EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO FACILITY, AND A BRIEF DESCRIPTION OF DUTIES i
PERFORMED WHILE SERVING IN THAT POSITION, IF MORE SPACE IS NEEDEO, USE COMMENTS (ITEM 17), OR IF NECESSARY, i
ATTACH ADDITIONAL INFORMATION, 17, COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON T CATION FORM, IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.
TION.
18.
NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 19.
SIGNATURES - SIGN AND DATE ITEM 19.a. ODTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOU MANAGEMENT REPRESENTATIVE ON SITE.
EETACH THESE INSTRUCTIONS AND SUSMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES PRIATE REGIONAL ADMINISTRATOR,
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FORWARD ConsestNTS REGARDING DURDtN tsidMAtt i
Con'"Y PERSONAL QUALIFICATION STATEMENT-LICENSEE To TH6 'N'oaMAYo= *wo a5coaD5 ""AS'"sMts.
IP 6303 U$ IdOCLEAR RGOULATORY DRANCH SiON, W ASHINGTON. DC Schtt. AND TO THE P APtfRif0RK ht DUCTION PROJECT (31604KHlos. OF F 4Cf Of M AN AGE-TO REMAIN VALID,1Hil FORM MUST NOT DE ALTERED MENT AND SUDQt T, W ASHINGTON. DC 30h03.
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18, DIRC PORM 308. CERTIFICATION OF GAEDICAL EMAMINATION SY F ACILITY LIC8088EE, IS ATTACHED ANY F ALSE ST ATEMENT OR OMISSION IN T His DOCUMLNT. INCLUDING ATT ACHMENTS, MAY DE SUWECT TO CIVIL AND CRIMINAL SANCTIONS.
N un en, inmense== et engury the the casenneiton in ihm encument and seischments N wun and eenut. l tunha eenity that i novo neutied m, eunem envieve et 111 em egvious eneneyws; e sente, umser senemy 1 new tuen names e, a washh em Human ee<wes inMai conwee Drue iemiao Leemrei ev ee e Licenese's iemine erint, we secoho er e commoes summenee.ene we int s
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$100eATURE AFPLICAlit DAfg CHECK APPLICASLE 80X b l contif team the shoe named louder 6ewel het succeentuhv comeveted the le,ctiny lereneses reauteememt to be licensed es en Opstaterften6er Oseemer pursuent to Totte 10. Coos e4 f enerei Resutetens.
Part 06:Gud that the bellutsuel has e nuell ter en Oeeroseettenee Overste 6eense to portoem heather seespied duties efeti that the sesene.mHI le mese sumHehle ter esemesueton.1 oteo sertaty uneet peelefty of pegueV thet the Mtsemeteen in thee document eved sitschments is true este sones _
$ RtNOW AL ONLY - I certify ensi the shove ns.ned inseriesuoi eneste the meseved eessualifisesion pesereen serven eseepeAsses seeses e, teenie ipJ ei e ouiewd tw section to 64164) et to CF R 60 and that he/she het seecheryd tenthee tecessend.
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CERTIPlCATION OF MEDICAL EXAMINATION W o,,cgl=a",'j,,".'.c a^,a"n*lggagyll=
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F AciLif v lF ACILif t DOCAti NutaDE R A. MEDICAL E KAMINATION CE RTIFICATION i
Tul$ 15 TO CI RTIF Y THAT THE ABOVE NAMED APPLICANT F OR AN OPE RATOR'LENIOR OPI RATOR LICENSE MAS Sk(N t RAMINED BY A PHYEICIAN PRINT 4 D N AMt tot anyi,c. ens l51 ATL AND LiC4NLL NUMetR l E k AMIN AfiON D ATE S Abt D ON THE RE 5ULTS OF THE ( R AMIN Af SON INCLUDING INFORMAfiON F URNISHE D 6Y THE APPLICANT T HE PHY$iCI AN H AS Ct1 ERMINED TH AT THE APPLICANf'S PHY$1 CAL (DNDITION AND GE NL R AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAU$t OPE R AflON AL 4 RRORS ENDANGE RING PUSLIC HE ALTH LHD $AF ETY. I Cf RTIF Y THAT IN RE ACHING THIS DtitRMINATION THE GUIDANCE CONT AINED IN ANSI /AN5 3 A 1983 OR ANbl/AN516 41977 iN3rH WAS FOLLOWE D AND THAT DOCUMENT A110N 85 Av AILABLE FOR Rt vitW tv NRC.
ON THE SA$lS DF THE RECOMMENDATION OF ttifHYSICIAN ICECOMMEND THAT THE APPLICANT'S OPE R ATOR LICENSE Bt CONDITIONIO AS FOLLOWS
- 1. NO RtETRICTIONS
- 1. HE ARING AlD 61 WORN WHtN Pt RFORMING LICE N$f D DUTlt5 Rt178tlCitD LICE Nst OR E XCE PTION ><ovitte netvi peio* end arisch suptmirime meaical evioence tot NRC eevie.
4 i
6 Rt $TRICTION CHANGE F ROM PRt vlOUS SUBMITT AL Pinv oe neiads tieen emt attach supportmo medicai evinence for NRC review h0 POSED WORDiNO OF RESTRfCTION tstura 4 etows
, E LATION5 HIP DF MIST FliCTION TO DISOUAltF YtNG CONDITION tartetty mrtscere how restraten wellcorrea the ssacuelsfysng contritson; RE MAR S FOR Ri$f RICT ON CHANGE 18 doca 6 dtio*J
- 6. NONMLDICAL CLRilf ICAIlON POWE R RE ACTOR 5 THIS CEnfielEE THAT NL APPLICANT HA5 Sit N FOUND TO ME E T THE SAF f GUARDE' AND F11Nibb FOR DUTY REOulR!ME NT5 0F ' 5 F ACILITY FOR LICENS1D OPER ATORS NON POWE R RE ACTORS THIS CLRTIFitS THAT Ted APPLICANT HAletEN FOUND TO Mitt THE SAFtGUARDS' REQUIREME NT5 0F THIS T ACILITY FOR LICE NSED OPE R ATOR$ AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT 't XCitDING THE CUTOF F LEVELS FOR ALCOHOL OR CONTROLLED SUBST ANCl$ A$ ($1 ABLISHE D PURSUANT TO 10 CF R 26 j
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,sm>unv twat fut imeonwariosiIN THis Docuss mi aNo arTacHuthYs is snus amo comanc1.
PAINT E D N AME AND $4GNATURL ($ener 4earingement nearementatew on 5,re; Tif LE DATE in actoroance witn 10 CF R 66 6. Commumcationi,ihn toem shan be submitted to the NRC at toitows 8Y MAIL ADDREL5LD 10.
I Regenal Admmistrato#, Regeon i Regene Admmiittator. Region il Regional Admmatraior. Region ill U S. Nuciear Reguietary Commisuon U S Nuclear Requisto<v Commmen U S Nucles* Kegulato', Commmen 475 Auennale Road 101 Marietta Street. Sui's 3100 799 Roowveit Road Kong of Prusi.e P A 19406 Atlanta G A 30323 Gien ilivn. IL 60137 Regehat Adm.mistator. Region IV Regional Aamimstrator. Region v U S. Nuciear Reguierorv Commmien u 5 Nucisar Regulatory Commissen 616 Ryan Piana Ortu Suite 1000 1450 Mana Lane. Smte 210 Artmeton. T X 70Jil Wamut Creet. CA 94596 l
PRIV ACY ACT ST ATiME NI l
Pursuant to 8 U.S.C bS2aieH3L eriacted mto ten by wction 3 of the Privacy Act of ROUTINE USES The moormaten may he a4ciowa to an appropriate f ewei State. or 1974 Vobhc Lan 93$791, the blio mg statement is urmshed to moividuais who local agency in the event the informaten indicates a vinistion or potentias violaten of iae s
suppiv mtoemation to the U S Nuciest Regulato,y Commaien on NRC Form 396 and in the event the m'ormaten mdecates a vioisten or cmieni.as vionalen of iew and in This mioematen it mainismoo in a symm et recoros neignaied as NRC 16 and the course of an admmistrative or suchcies oroceeding in samten th.i mtormaten may t>e oncribed at 61 F ederal Regator 33157 (Sepiember 18.19861 transtened to an appropriate Femai. Siate and soce agency to the entent reiennt and necenia'v 'O' aa NRC decevon atwut you AUTHORITY Sectens 107 and 16tbl of the Atomic Ene'ev Act of 1954 as amenood t42 U $ C. ?t37 and 2201M1 WHITHE R OtSCLOSURE IS M ANDATORY OR v0LuNTARY AND trFFCT ON PRINCIPAL PURPOSE (St inbematen emered on this form 4 und to oetermine INDIVIDUAL OF NOT PRoviDING INFORMAtiON D1iciosure in vo.unta,v et ine whether tne physical coritaiten and generai hesith of the apphcent are such that they reuweited intotmeten 4 not previoed however the app %aten tot a f acitely osw 3 tor's win not cause operatenai errori endange,mg pubhc hesith ann safety T hin informa o' isaer ope'ato' i heense may be nemed ten may be used by the NRC statt to oeiermme it tne mdevidual meets the require SYSTEM MANAGERtSI AND ADDRE$$ Cheet Operatoe Licensing B*anch. Ottice of ments of 10 CF R $$ to taae en summaten of to be iniusd an operefor s licenw Nucteer Ruciot Regulation, U $ Nuciec Regulato'v Commmen Annington. DC 20556 l
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i SCH%RY OF QUM3RS '!O 15C 1mmt 3M Medical Examination Certification Added black " Restriction Change Frta i
Pewicus Suhaittal" plus Remarks i
sectica.
ikm-Hodical Certification Onensed non-medical certification statement to: Peper Basetors-This t
certifies that the applicant has been fo nd to meet the ma % a @
- and fitness for thaty requirementa of this i
this facility for licensed operators.
Hanpower-this certifies that the applicant has been found to meet the i
mafarm4* requineenta of this facility for licensed operstors and
- t I have no knowledge of the applicant wing the cutoff levels for alcohol
'r or controlled substances as es*mbHaw puramant to 10 TR 26.
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DU460RE 4 SQtWRi 0F OIAIMB '!D REC PCR( 398 r
l Itan 4.d Added clarifying stataemit to indicate this is to be checked only if application is to==nd license to add additional unit (s).
Item 4.f Added "(Catesory)" to Operating.
Ad _ded i m,.i.
Item 4.g Added a new item "Date Poseed Generic Fundamentals i
Exmaination Section".
1 Itam 12.3 l
Changed wonfirc to " Certified Startup Progree completed" l
for clarification.
Item 12.5 Changed woniing to " Extra Perman Cn Shift In Control Hocs (13-week minima)" for clarification.
Item 12.5a Added a new item " Time On Shift Above 20E Peuer (6-week miniman)".
Itam 14.a Added the wonis "That Is Based Upon A SFBtems Aproach to Tr=4 aim" for clarification.
Item 15 Added "Date and Beault of Host Recent ta:C Amtered poqualification Em ainatica".
Item 19.a Added the wording "I further certify that I have notified ur current seloper of t (1) all prwtous employers; (2) any instance where I have been tested by a Health and thanc Services (151B) Certified Deur Testing W e.i or a Licensee's testing facility for alochol or a controlled substance, and the test resulta esoseded the cutoff levels established sursuant to 10 CFR Part 26; (3) any fastance where I have been arrested for the sale, use or possession of a centrolled sdwitanos described in 10 CFR Part 26; and (4) any reasons by removal or revoontion of unescorted aooems at a nuclear facility".
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Item 19 b and Item 19.c Moved 19.b and 19.c tesother. Applicable beat must now be chedted. Also added block for typed name of Training Cooniinator and Senior Manage===t Representative Ch Site.
ITR 16C USE Under waiver ceteer,ty added "tanMn.1.
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