ML20006D648

Discusses & Forwards Revised NRC Form 396,certification of Medical Exam by Facility Licensee & NRC Form 398,personal Qualifications Statement - Licensee

ML20006D648
Person / Time
Site:	05000199
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Berlin R MANHATTAN COLLEGE, RIVERDALE, NY
References
NUDOCS 9002140168
Download: ML20006D648 (8)

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Docket-No:- 50-199 g

Q Manhattan College Corporation.

iATTN: Dr, Robert E. Berlin-Reactor Administrator.

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. Manhattan. College Zero Power Reactor Q

c/o Mechanical / Engineering Department y

Riverdale, New York 10471' n

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Gentlemen:

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~ REVISED NRC FORMS 396'AND 398

SUBJECT:

Enclosed 'is-'al 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, g% <

'All" changes to the NRC Form-396'are detailed in Enclosure 3.

Changes' to NRC Fcem-398 are detailed in= Enclosure 4.

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A11 applications for licenses.are to becsubmitted on these' revised forms no L

_ later than Fet, vary 1,1990.-

The enclosed' applications-are for your use.. Additional copies-can be-obtained L

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by contacting Beverly Martin, U.S. Nuclear Regulatory Commission, by telephone-

(301)-.492-8138

or, by writing to her, U.S. Nuclear Regulatory Commission, it w

Information.and. Records Management Branch, Mail'Stop-NMBB 7714,; Washington,--

IQ D.C.

.20555.

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If'you h' ave any questions regarding -these forms, please contact' Richard J.-

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Conte'at-(215) 337-5120 or Peter W. Eselgroth-at-(215) 337-5211'.

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E Sincerely, Original Signed Byt" Robert M. Gallo, Chief Operations Branch i

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Division of Reactor Safety

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Enclosures:

As stated

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h 9U'A21%dk OFFICIAL RECORD COPY 396 & 398 FORMS - 0045.0.0 s.

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Manha,ttan College Corporation -

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Dr.'Jih-Pern0 Hu, Reactor Supervisor-.

- Dr. L. R. Solon, Director, Bureau of Radiation Control New York City Department' of Health -

Dr. William:Vernetson,_ Director of Nuclear Facilities,.

University of Florida Public Document. Room (PDR)

Local Public Document Room (LPDR)

. Nuclear Safety-Informat_ ion Center (NSIC)

State of New York-L

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- bec w/o encl:

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- Region I-Docket Room _(with concurrences)

Management Assistant, DRMA (w/o. enc 1)

D. Haverkamp, DRP' R. Blough, DRP-J. Lyash,-:DRP OL Facility. File-j

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01/02/9d7 \\d jbf hb OFFICIAL RECORD COPY 396 & 398 FORMS - 0046.0.0 12/14/89 e

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INSTRUCTIONS FOR COMPLETING NRC PORM 3BB PER90NAL OUALIFICATION STATEIENT-LICENBEE

' TO REMAIN VALID,THIS FOHM MUST NOT BE ALTERED z 4 f 4, TYPE CF APPLICATION 2.s NEW "X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE

. INSTRUCTIONS BELOW. THIS 18 TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE i

RECElVED UP TO THE DATE OF TH18 APPLICAT4ON. NOTE: SEE ITEM 14 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED lF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "NEW,"

2.b thru 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 ITEM 74 - THERE l$ AN EXCEI" TION.

2.b RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE.

' 2.c UPGRADE "X"lF YOU HOLD A RO LICENSE AND ARE NOV/ APPLYING TO UPGRADE YOUR LICENSE TO A SRO.

2.d MULTl-UNIT "X" lF 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 REAPPLYING.

F 2.f WAIVER REQUESTED "X"THE. APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

2.g DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES),

j 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 (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 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 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 ADDI.!

TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17).

- 12.

TRAINING - 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. REFER TO THE STANDARDS IF YOU NEED FURTHER CLARIFICATION INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED, IN ADDITION TO BEGINNING AND COMPLETION DATES,

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TO ACCOUNT FOR INTERMITTENT TRAININ3 (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2. MONTH i

p PERIOD), THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS 4

, SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13).

' ALL REQUALIFICATION TRAINING TIME !S TO BE ACCOUNTED FOR IN THE REOUALIFICATION ITEM. PLEASE DO NOT" DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME.

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13. -

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR EACH l'3SITl3N i

HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASF. SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

14.

FACILITY OPERATOR TRAINING PROGRAM - lNDICATE a. GR ADUATE OF INPO ACCREDITED OPERATOR TRAINNG PROGRAM:

• • !ED (ON NRC FORM 474) OR NRC APPROVED SIMhTG cm,u.aii so vacu m a nc UrmAIUH TH AINING RRO.

GRAM. IF "YES" IS 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 THE NATIONAL NUCLEAR ACCREDITING DOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE l.8, REV,2, ARE MET.

15. - FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUAllFICATION EXAMI.

NATION, 16.

EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFOhMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEEDED, USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATION.

17.

COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPL CAT)ON FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFURMATION 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 194. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAi. AND TWO COPIES EACH) TO THE A

- PRIATE REGIONAL ADMINISTRATOR.

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Nhc PORM SN u.k NUCLE An AEAULATORY COneslaslON g,,noyg,A DV Ohk NO.396041000 DAT E wECElvED 1

E KPIRE 8: 13142 ID# M N C#

l-USM ' 6.31 te.36, 10 Cp A 9 I

lh AT,esus 9617 ESTIMATED SURDEN PER RESPONSE TO COMPLY WITH i

THl$ INFORMATION COLLECTION REQUEST: 2D HR$

1 FORWARD COMMENTS REGARDING BURDEN ESTIMATE 1

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, PERSONAL 00ALIFICATION STATEMENT-LICENSEE.

to THE INFORMATiON AND RECORD: MANaoEMENT

$ RANCH (P.610), U S huCLE AR REQULATORY COMMis.

-- l SiON. WASHINGTON DC 20bt6. AND TO THE PAPERWORK q

REDUCTION PROJECT (39604000s. OFFICE OF MANAGE.

TO REMAIN VALID,TH!$ FORM MUST NOT DE ALTERED.

MENT AND BUDOET WASHINGTON. DC 20603.

1. APPLICANT'S FULL NAME (Last, Ekst,idi&tte) AND ADDRESS (he/ucfrl/P CtNfe)

4. TYPE OF APPLICATION (Check aRp/ra6/e 60/m) i-l

e. REAPPLICAf f0N 1

f. #AlvER REQUESTED

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2. OPE RATING (Cese.

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3. THIRD

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3. E L10lelLITY 6, MULTIAINIT (AMEND TOINCLUOf ADDITIONAL e. NEDtCAL

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3. BIRTH DAT E UNITI 5.OTHER g UNITED STATES MONTH DAY YEAR

g. DATE PASSED GENERIC FUNDA.

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5. TYPE OF LICENSE APPLIED FOR

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8. NJ.ME OF APPLIC ANT'S F ACILITY F ACILITY DOCKET NUMBER

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INSTRUCTOR i

9. ADDITION AL F ACILITY DOCKET 8 IMustsenst &wenerst s SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR 4

11. EDUCATION 1

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s. MAJOR AREA 183 OF STUDY

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13. E XPERtENCE (D0 NO T DOUBLE COUNT-SEE INSTRUCTIONS)

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12. SHIFT SUPERVISOR Ilmenanff 6 REQUALIFICATION -

13. STAFF / SHIFT ENGINEER (tken nri 7 -OTHE R (sous&#

14. AUXJEQUIP. OPERATOR (Nonteensuff

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15. FOR RENEWALS ONLY O!.

b. DATE AND RESULT OF GAOST DATE noeutY

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18, NRC PORM 398. CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LICENSEE,18 ATTACHED

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ANY F ALAE STATEMENT OR OMISS40N IN THis DOCUMENT, INCLUDING ATTACHMENTS MAY BE SUBJECT TO CtVIL AND CRIMINAL SANCTIONS.

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10s. I eartwy weser senehy of sortury shot the inseementon in this oneumont end etterwenis 6e true and sorrect. I turther eeruty that I how notifes my surrem omspever of: 61) en previous enseevers

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~.12) eny knetenes where I hee timen tested tev e Hestth eral Human terwesellHHS) Certifmi Drue Testene Lenoretory or e Licenese

' of a controleed maketense desenhed a 10 CPR Port 28..

and l4i en,oded the auseet sewets ausenehad puresent to 10 CFR Port 26;13l any instance where I have tseen errested for the eses,'s te

f i sueuste oneg use er.

russene tot renwuei er neveestion of unserorted emeens et e nuceemet toenety, I eies authoeta the NRC to meewnu the ruusts el emeransimas to env empsovers ser use e propertne retreuune Usagrame. ea sseessary 4s

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8804ATU8tl.AFPLACANT <

DATE-

.i CHECK APPLICASLE DOX

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- k isertNy that the ehmen named 6ndiw6 dual han sucesesfuHv sompleted the facil6tv heeneens reeversements to tie 14cented e en Opereforisoner Operseer pursuant to Title 10. Code of Federal Resuietens..

. Port ES;and thee ene Weseshhand has e need ter en Operegor/Santer Operator lesense to perform hes/her sesgned Guttes and ther the manay men be made se60thm for enemmassen. 4 eles certte under e

v penalty Of pertury tfist the intermetion in thee document and setettunents le true arist entract, c

e6 RENEW AL ONLY - I certify 'her the eteve named indiveduel enests the sperowed requellfleetton proerem (wist escoordone nefeat As trem FFJ es requ6ted tsy egetton 60.64161b of 10 CFR 40 end -

9 that holine has diectierged ens /her licensed responut>Wnese corroeteritly end estety.1 eleo sortify under pensitY of pequry that the inforenetson in thee encement end etternrnents is teus and cormei.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE P9 TENTED OR TYPED NAME PRINTED OR TYPED NAME i

lDATE 54GNATURE lDATE l

SIGN ATUR E 7

FOR NRC USE WAIVE R (Check or Comphre items, es appliceWel l MEETS REOutREMENTS l l DOES NOT MEET REQuRbMENTS isspaws eenwl

""" D ' 'n E QlON He ADQU ant k n"$

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'DC "2065.'"AND T"'TMt P APE.v'o'o" stet "C.

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b SiON W ASHIN,G et0>tCT (31b0002a1 088tCE OF M48e AGE.

at DUCTION MENT AND.UDGE T,14 ASHINGTON. DC 200o3.

NAML OF APPLICANT l F ACILITY DOCl(E T NUMBER F ACILIT Y A. MEDICAL EXAMINATION CERTIFICATION ir41$ 15 TO CERTIF Y THAT THE A80VE NAME0 APPLICANT FOR AN OPERATOR / SENIOR OPERATOR LICENSE MAS BEEN EXAMINED SY A PHYSICIAN MIN TED N AME (of physmans l STATE AND LICENSE NUMBER l EXAMINATION DATE BASED ON THE RESULTS OF THE EXAMINAflON. INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED TH AT THE APPLICANT'S PHYSICAL CONDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATION AL E RRORS ENDANGERING PUBLIC HE ALTN ANO SAF ETY.1 CE RTIFY THAT IN RE ACHING THIS DETE RMINATION. THE GUIDANCE CONTAINED IN ANSI /ANS 3 41983, OR ANSI /ANS 16 4-1977 (N399) W AS FOLLOWED AND THAT 00CUMENTATION IS AVAILADLE FOR REVIEW BY NRC ON THE BASIS OF THE RECOMMENDATION OF THLfHYSICIAN, i RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:

1, NO RESTRICTIONS

2. CORRECTIVE LEN'ES BE WORN WHEN PERFORMING LICENSE 0 0UTIES

3. HEARING AIO BE WORN WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICENSE OR E XCEPTION Provide detads below and attach succortmg medical evidence for NRC review.

5. RESTRICTION CHANGE F ROM PRE VIOUS SUBMITTAL Provide aetads besow and attaen supportmg medice evidence for NRC review.

PnOPOSED WORDING OF RESTRICTION I8/ock 4 ecove; AELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION (87artly mecate how resencien wellcorrect the &squehtymp conastsont REMARKS FOR RESTRICTION CHANGE (8/ock 5 acow; 8, NONMEDICAL CERTIFICATION POWE R RE ACTORS:

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUAROS' AND FITNESS FOR DUTY REQUIREMENTS OF THl$ F ACILITY FOR LICENSED OPE RATORS.

NON POWER RE ACTORS.-

THl3 CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS

• REOL"REMENTS OF THIS F ACILITY FOR LICENSED OPERATORS. AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUSSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26.

p.v F ALsa st AreMeNr on omission aN rms occuMeN T. >NCLuOING AT t ACHMEN t3 MAY ee SusJLCT YO civit AND CRIMINAL SANCriuN5. a ctH w v UNukN FtNALIV of rERJumv THAT THE INFORMATION IN TMi$ DOCUMENT AND ATT ACMMENT5 IS TmuE AND CORRECT.

1RINTED NAME AND SIGNATURE (Sener Management Representer,w on S,tel TITLE DATE in accoroance witn 10 CF R 55.5, Communicanons. tnis form shall be suomitted to the NRC as follows: 8 Y MAIL ADORESSED TO.

Regional Admemstrator. Reg.on i Regional Admmistrator Region il Regional Administrator. Region ill U S. Nuclear Regulatory Commission U.S. Nuclear Rewiatory Commessen U.S Nuclear Requiatory Commisseon 475 Allendste Road 101 Marietta Street. Suite 3100 799 Rooseveit Road King of Prussia. P A 19406 Atlanta. G A 30323 Gien Ellyn. IL 60137 Regenal Admmistrator. Region IV Regerus Ademistrator. Reg on V U.S. Nuclear Requtatory Cornmission U 5. Nuclear Regulatory Commission 611 Ryan Plau Onve. Suite 1000 1450 Mar a Lane. Suite 210 Artmeton. TX 76011 Walnut Creek, CA 94596 PRIV ACY ACT ST ATEMENT Pursuant to 5 U.S.C. 552atell31. enacted mte law by section 3 of the Pnvecy Act of ROUTINE USES The mformation may De d.sclosed to an appropriate Federas. State. or 1974 IPubhc Law 93579L the ollowmg statement is 'urmshed to mdivouais *no locai agency m tne event the mformation nuncates a violation ur potential violation of law r

supply informaten to the U.S Nuclear Regulatory Commassen on NRC Form 396 and m the event the informanon mdicates a viotapon or potennal violaten of law and m This mformaten is mamtamed m a system of records desig $4ted as NRC 16 and the course of an admmistraove or ludicias proceedmg in additen. en.s mformaten may be described at 51 Feders Register 33157 (September 18,1986L transferred to an appropriate Federal. State. and locas agency to the extent relevant and AUTHORITY: Sectens 107 and 161ti) of the Atomic Energy Act of 1954 as necessary for an NRC decrsion acout vou.

amendvo l42 U.S C. 2137 4ad 220llill.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISl: fntormation entered on this form is used to determme INDIVIDUAL OF NOT PROVIDING INFORMAflON D.sclosure.s voeur tsrv. If tne

• nether the physical coret on and general health of the apphcant are sucn inat they rmuested mtormanon is not provided. however. the aconcaten for a facihty operator's wdl not came operatenas errori endangenng puenc health and safety. This mforma-or semor operator s ucense may be cenied

- ten may be men by the NRC staff to determme if the mdividuas meets the require-SYSTEM MANAGERIS) AND ADDRESS. Chief. Operator Licensmo Branen Office of ments of 10 CF R 55 to tame an esammaien or to be issued an operator's license Nucieer Reactor Regulation. U.S. Nucmar Regulatory Commiscon. Washmgion, DC 20555

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INCID60RI 3 St2fRIN OF QiANGES '!O IGIC POIM 396 j

F Added block "Bestrictica Omse Frem Hari4r2r Examination Certification Prwious Sukaittal" plus Remarks 1

emotica..

1 Non-Medical Certification mansed non-==ri4a=1 oertification statement to:. Pbwer Beactors-This certifies that the applicant has been found to most the==farmetis' and

. fitness for duty requirements of this this facility for licensed operators.

Hanpouer '!his certifies that the applicant has been found to aset the safesuards' requirements of this facility for lin====rt operators and-.

I have no knowledge of the applicant

====rting the autoff ~ levels for alcohol or controlled substances as established

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parsuant to 10 CFR 28..

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,g, D U DSURE-4 e

s StRetARY OF CHAtG5 TO lEC FORI 398 Itam 4.d Added clarifring statament to indicate this is to be

. i checked only if application is.to amend licones to add additional tait (s).

Item 4'f Added "(Category)" to Operating.

Added "Mediaal".

Item 4.s Added a new item "Date Passed Generic Fundamentals Exandnation Section".

p Item 12.3 Changed wording to " Certified Startup Pmgram Completed" P, +

for clarification.

Item 12.5 Changed wording to " Extra Person On Shift In Control Boom (13sesek minim a)" for clarifloation.

Item 12.5a

- - Added a new item " Time On Shift Above 20E Power (6-week minima)".

w Item 14.a Added the words "That Is Based Upon A Systems AwM to Tr=4aia=" for clarification.

Item 15 Added "Date and Beault of Host Recent NRC Administered L

Degualificatica Eummination".

-i Item 19.a Added the wording '"I Aarther certify that I have notified.

O ar current ausdayer of: (1) all pewfous essdayersi (2)-any l

instance where I have base testal br a Health and Human l~

Services (HHB) Certified Dms Testing Le-.6Ei or a Licensee ~c testing facility for minahal or a controlled' substance, and the teet resulta M the cutoff levels

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established pursuant to 10 CFR Part 26; (3) any instance where I have been arrested for the sale, use or possession of a ocntaclled substanos described in 10 CFR Part 26; and (4) any reasons for rumpval or rwvocation of unescorted aooess at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c tegether. Applicable box mast now be

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checked. Also added block for typed nose of Training Coordinator and Senior Menesement "--;- mt tive On Site.

t,e POR NBC USE Under waiver category added "Medinal".

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