ML20006D655
| ML20006D655 | |
| Person / Time | |
|---|---|
| Site: | National Bureau of Standards Reactor |
| Issue date: | 01/05/1990 |
| From: | Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Rowe J NATIONAL INSTITUTE OF STANDARDS & TECHNOLOGY (FORMERL |
| References | |
| NUDOCS 9002140176 | |
| Download: ML20006D655 (8) | |
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JAN 5 1990 D6cket No: 50"184 E
U. S. Department of Commerce
-National Institute of Standards and Technology ATTN: Dr. J. M. Rowe, Chief Reactor Radiation Division Gaithersburg, Maryland -20849 Gentlemen:
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SUBJECT:
REVISED NRC FORMS 396~AND 398 Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal
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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)492-8338 or by writing to her, U.S. Nuclear Regulatory Commission,
-Information and Records Management Branch, Mail Stop NMBB 7714, Washington, D.C.
- 20555, t
If.you iiave any questions regarding these forms, please contact Richard J.
Conte at'(215) 337-5120 or Peter W. Eselgroth at (215).337-5211.
Sincerely, Original Sieman WI Rebert M. Gallo, Chief Operations Branch Division of Reactor Safety
Enclosures:
As stated
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0FFICIAL RECORD COPY 396 & 398 FORMS - 0061.0.0 12/14/89
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T. Raby; Chief, Reactor Opera'. ions
.J J..Torrence, Deputy Chief, Reactor Operations Dr. William Vernetson, Director of Nuclear Facilities, Univer!,ity of' Florida l'
.Public Document Room (PDR)
Local Public Docum'ent Room (LPDR) r Nuclear Safety Information Center (NSIC)
State of Maryland (2)
.j bec w/o enc 1:
Region I Docket Room (with concurrences) j:
Management' Assistrat, DRMA (w/o enc 1)
L. Tripp, DRP-D. Haverkamp, DRP D. Limroth,'.DRP s
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H. Eichenholz, SRI - Calvert Cliffs OL Facility File 1
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0FFICIAL RECORD COPY 396 & 398 FORMS - 0062.0.0 12/14/89
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INSTZUCTIONS FOR ODMPLETING NRC PORM 388 PERSONAL QUALIFICATION STATEl'.ENT-LICENSEE TO CE%AIN VALID,THis FORM MUST NOT BE ALTERED 4.
TYPEOF APPLICATION 2.s NEW
- X" lF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWWG THE INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECElVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE ITEM F4 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF 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 f4 - THERE IS AN I
EXCEPTION.
2.b RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE, 2.c UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YGUR LICENSE TO A SRU.
2.d MULTI. UNIT "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.s REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.
2.f WAIVER REQUESTED "X"THEAPPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).
2.s DATE PASSED 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 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 OF A UCENSE. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.
11.
EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION FOR MAJOR AREAIS) 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. I 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 S IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT F081 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 j
SPENT IN FULL TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER I
EXPERIENCE (ITEM 13).
ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE DO NOT " DO l
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 REGUIRED. FOR EACH PO 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 CASE 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 - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING WDh e58mMED !ON MRC FORM 171) OR NGC APPROVED SIMULATION FACILITY 15 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),
AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE OOCUMENTED. NEW APPLICATIONS MUST STILL INCLUDE THE NUMB OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.8, REV. 2 ARE MET.
- 15.
FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE O LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION EXA NATION.
EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES 16 PERFORMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEEDED, USE COMMENTS (ITEM 17), OR IF NECESSARYr ATTACH ADDITIONAL INFORMATION.
i 17.
COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APP 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.
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- 19. '
SIGNATURES - SIGN AND DATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR *S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPR ESENTATIVE ON SITE.
DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO THE PRIATE REGIONAL ADMINISTRATOR,
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2 GEDC #db SSB U.E tlWCLEAR RE4ULATORY CORAtletices APPROVE) SY ORAB: NO. 31604000 D4TE RECElvtD UOO'A 56.31,66.36, I
EMPIIES. I41Q O' 8' N
- NC#
to CF 47, ond.4.61 ESiltsATED DURDEN PER RESPONSE TO COMPLY WITH THl3 INFORMATION COLLECTION REQUEST 2A HMS.
FORWARD COMMENTS REGARDING DURDEN E STIMATE
. PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE IN'OaMATION AND RECORDS MANAGEMENT BRANCH IP-6304, U.S. seUCLEAR REOULATORY COMMis.
SaON WASHINGTON. DC 2tabte AND TO THE PAPERWORK REDUCTION PROJECT (316040001, OFFICE OF MANAGE.
TO REMAIN VALID,THIS FORM MUST NOT DE ALTERED MENT AND DVDGET.W AsHINGTON, DC 70503.
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- 1. APPLICANT'S FULL NAME (IsW,firW, AfsWiel AND ADDRESS (melualeItP Cbdy)
- 4. TYPE OF APPLICATION (Chere app /kaWe bemes) i i
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- 3. E LIOle4LITY G. MULTI. UNIT LAnttNO TOINCEVOE ADDITIONAL e. MEDICAL
- 2. CITIZENSHIP
- 3. BIRTH DATE UNITI
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- g. DATE PASSED OENERIC PUNDA.
MM YY MENT ALS EN AMINATION SECTION
- 6. OTHER tsoortNb l
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- 5. TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LICENSE (S) HELD s OPERATOR
- s. DOCKET NUMSER RO SMO k LICENSE NUMSER (g
- d. F ACILITY DOCKET NUMBER l
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- s. LIMITED SRO te p.. Fust Handspel l
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- 10. CURRENT POSITION AT FACILITY
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- a. PLANT $UPERINTENDENT LA 4 g I
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- l. OTHER (Specd4J
- 5. NAME OF APPLICANT'S F ACILITY F ACILITY DOCKET NUMBER
& SHIFT TECHNICAL ADVISOR / SHIFT ENQiNEER
- f. INSTRUCTOR
- 9. ADDITIONAL F ACILITY DOCKETS (Arversgamr treners#
S SENIOR CONTROL ROOM OPERATOR A CONTROL ROOMOPERATOR
- 11. EDUCATION g Hi1H SCHOOL
- e. MAJOR AREAlta OF STUDY
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- 2. ASSOCI ATE 3*8ACHELOR
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- 13. E XPE RIE NCE (DO NOT DOUBLE COUNT-SEE INSTRUCTIONSI
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1 -NUCLEAR POWLR PLANT FUNDAMENTALS roomi 1.RO 2 -PLANT SYSTEMS 2 7EOOW/PPWO CLASSROOM
- 3. EWS/IPWS OBSERVATION
- 4. E RS/CRW 3-OPE RATING PR ACTICE
- 5. OTHER ISpec,4A CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPERATING tir.rsuses CJswoomJ FOSSIL SIMULATOR NAMES
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- 10. RE ACTOR OPERATOR ILicens ds 5 -$g'n'O,".,"v$8H'" 'N CON I"
- 11. SENIOR OPE R ATOR ttscenseds
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- 15. PLANT STAFF 16.OTHER tsa es&i NRC FORM 396110491
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. inAsenses retoonAu THAT is eAseO UPON A YES NO ce:TTar#CATsonr") Da senc ApPstovsp 8IMULATeoes YE$.
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. SV5 Fees AppetOAON TO TRAlesessG e,AC#Lif Y es useo IN THE OPtRATOR TRAlenNG pnoanny
- 15. FOR RENEWALS ONLY D' '
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k DATE AND MtSULT OF MOST -
RECENT NRC ADMINISTEREO se0VftS OpenATED F ACILITY:
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- 16. EXPERIENCE DETAILS ew POstTIOe8 TITLE PMott TO -
4 F ACILITY sL DUTIES i
- 17. CORSENTS dhesaw see deem aumer se uma roe one
. Anese essmdeneramens as seemeeryJ
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- 18. N AC PORM alls. CERTIFICATION OF MEDICAL EXAMlNATION SY F ACILITY LICENSEE;IS ATTACHED ANY F ALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATT ACHMENTS. MAY BE SUBJECT TO CIVll AND CRIMINAL SANCTlONS.
h I earttty under penesty of segury that the 6atormetton in inn desumeni and sneeneneme is true end correst. I sunner eert6e tnet I seue notihan sny surrone enipsever of: tin en seemous empiovers; v
' (2) any enmenee enliese I lieue tem tested tMr e Heelen end Human eerstese (HMS) Certatted Drue Testing Laserstory or e Leseness's tesigne tenistry for steenet or a controssed esessmee, and the test ressete ausseded toe autoff tosses essenhened pueuserit to 10 CPR Port 26;(3) env inesense where i Iowe Issen errested for tne sete. use er oneeseamm of a son:veseed ashetence desertand an to CF R Part 26; and (4) any steemas ter removal er reveestion of unesserted essess et e austeer10sellMy, I ease eutnertse the NMC to sabrna the reeutte el eeenungeons to my emesevers for ues e peepering retrainene seasseme,a sessmerv SIO4ATURE-APPLaCANT DATg CNECK APPLICABLE BOX k i eeniw ener one enew named leasemeshnes hee aussese#un, comoieted tne teeinev amensens resuirenums to en noensed as en opersierteenior osseeror pursuant to Tate to, Case et Federei Resumtens.
pen es:end esse tem tideseases nas e need eer en oserneriennier osuuser Heenes to persona navner essened gutes seus ther one - ~
es made sausam ser essen6neuen. a peo senie under v
sonen, es sortery enes tne insonneelen en enn aseemeen end eneenments b true end eerrest.-
6 RENEseAL ONLY = l eartify tnet the ahnve named indtvedual meets the aperoved voeusHfteetion proerem lurirA empreens assed er hem #1) es feoutred by section 60.64 (i H of 10 CF R 60, and enet nenne nm degenerged fue/ner heensed teamenseWNes earnpetently and glely, 4 steo senth under pensity pf Delury tnet tte intonnenon in tne document and snecntneritt is true end sorrect.
TRAININO COORDINATOR SENIOR MANAGEMENT REPRESENYATIVE ON SITE PRINTED OR TYPEO NAML PRINTED OR TYPED NAME lDATE l Daft SIONATURE StQceATURE FOR NRC USE Wi.IVER (Check or Conwiere iterns, es applicebde) l MEET 8 REQUIREMENTS l l D018 NOT MEET REQUIREMENTS Mededa awdowl OR ANTf D e v DENIED eV 7ggy -
HEADQUARTER $
R e O80N HEADQUARTERS R e GION ERITTEN -
OPERATING ELIGIBILITY -
saoNATURGREviEvrER DATE MEDICAL OTHER senc Fonen see tioso)
a U.S. NUCLE AA nEGULATO4Y COnsaistS$10N a.ePRovio ev on.es No.stescots N,R.C,s, ome 3B mai sas.
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wsNT AND SvoGET.nasMINGTON DC 70603 NAME OF APPLICANT F ACILIT Y lF ACILITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATlON THl$ l$ TO CE RTIF Y THAT THE ABCVE NAMED APPLICANT FOR AN OPERATOR: SENIOR OPE R ATOR LICENSE H AS BEEN E XAMINED BY A PHYSICIAN.
PRINTED NAME tof physicsont lST ATE AND LICENSE NUMBER l ExAMIN ATION DATE B ASED ON THE RESULTSOF THE EXAMINATION INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT *$ PHYSICAL E)NDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATION AL E RROR$ ENDANGERING PUBLIC HE ALTN AND SAF ETY.1 CERTIFY THAT IN RE ACHING THIS DETERMINATION. THE GUIDANCE CONT AINED IN ANSI /ANS 3 41983.OR ANSI /ANS 15 41977 (N3so) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC,.
ON THE BA$ls CF THE RECOMMENDATION OF TELfHYSICI AN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AfD BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR E XCEPTION Provide aetails below and attach supportmg medicas evidence for NRC review.
5 RESTRtCTION CHANGE F ROM PREVIOUS SUBMITTAL Provice details beeow and attach supportmo medical eveaence for NRC rev.ew.
PROPOSED WORDING OF RESTRICTION (Stock d *DrM,
AE LATIONSHIP OF RESTRICTION TO DISOUALIF YING CONDITION (8rretty mdscare now restrafen wrticorrect the esque/sfy#ng condirent REMARKS FOR RESTRICT 10N CHANGE (8Aoca 5 acows B. NONMEDICAL CERTIFICAllON POWER REACTORS:
THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THis F ACILITY FOR LICENSED OPER ATORS l
NON-POWER RE ACTORS.
ThlS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUAROS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS. AND i HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 l'ERJURY TM ta reueNr on owissioN iN YMis occuuaNY. Netuo Nu ar racMueNrs. uar se susaect ra civit aNo cnimiNat uNe rioNs. i ctHi m v uNueH e aNv *atse s T Teet IN80 Rwa rION IN TMiS DOCUMENT aNO AT'TaCMMENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE (Sensor Manevement Repreernrarne on Strei TIT LE DATE l
l In accorcance witn 10 CF R 56.5. Communications. Ines form shall be subrnetted to tne NRC as follows: B Y MAIL ADDRESSED TO.
Regional Admmistrator, Regen i Regenal Admmistrator. Regen ll Regenat Admmistlator Regeon ill U.S. Nuclear Regulatory Commessen U.S. Nuclear Re@latory Comminion U.S. Nuclear Regulatory Commissen 475 Allendale Road 101 Marietta Street. Suite 3100 799 Roosevent Road Kmg of Pruusa PA 19406 Atlanta. G A 30323 Gien Ellyn. IL 60137 Reg,ona6 Administrator. Region IV Regional Administrator Region V U S. Nuclear Regulatory Commissen U S. Nuctear Regulatory Comminen 611 Ryan Plau Drive. Suite 1000 1450 Mana Lane. Suite 210 Arimaton. TX 7601)
Walnut Creet. CA 94596 PRIVACY ACT STATEMENT
- ursuant to 5 U.S.C 5524(eH31. enacted mto law by secten 3 of the Pnvacy Act of ROUTINE USES: The mformation may be disciosed to an aooropriate Federas. State. or 1974 (Publee Law 915791 the followmg statement #s turnisned to individuais wno locai agency m the event tne mtormaten indicates a vioiation or potentias violaten of law suomy mfortristen to the U.S. Nuclear As9utatory Commission on NRC Form 396 and m the event the mfortaation mdicates a viotaten or potential violation of law and m This mformaton is mamtamed m a system of records desegnated as NRC 16 and the course of an aaministrative or audicial proceedmg in addition, this mformaten may be described at 51 Federal Register 33157 (Septemoer 18.1986).
transferred to an acorooriate Federal State and local agency to the entent retevant and AUTHORITY: Sect ons 107 and 161M of the Atomic Energy Act of 1954. a, necenary for an NRC decision anout you.
amenced (42 U S.C 2137 and 2201till WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROvlDING INFORMATION. D>sciosure is eviuntary. If the PRINCIPAL PURPOSEISh informaton entered on this form is used to determme
'equested informat.on is not provided. nowever. the acobcaten for a facihty operator s weetner the onysical condition and generai heaath of the appucant are such that tney will not cause operatenas errors endangermq pubhc hesitti and safety. This mforma or senior ooerator s scense may ne cenied tion may be uses by the NRC staff to determme if the marvidual meets tne recuire-SYSTEM MANAGER (St AND ADDRESS Chief Operator Licensmg Branch Office of ments of 10 CF R 55 to taae an e Ammaten or to be inued an operator's license Nuclear Reactor Regulation. U.S. Nucisar Regulatory Commin on. Wasnington, DC 20555.
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ENCIASUIE 3 SmitARY OF CHANGES 10 IGC P0Ett 396 -
-Medical Examination Certificatim Mded block."Bestriction Change Free Prwious Sutunittal" plus Remarks emotion.
Non-Medical Certification Changed non-medical certificatica statement to: Power Beactors-This certifies that the applicant has been found to most the safeguards' and fitmana for duty requirements of this 1
this facility for licensed operators.
Nonpeuer-This certifies that the applicent has been found to meet the safesuards' requirements of this i
facility for licensed operators and I have no knowledge of the applicant
==mariing the cartoff -levels for al*1 or controlled substances as es+=h14=hari pursuant to 10 CFR 28.
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EHCLOSURE 4 SUtttARY OF CfWUES '!O HIC POEM 396 Item 4.d-Added clarifying statament to indicate this is to be checked enly if application is to amend license to add additional unit (s).
Item 4.f Added "(Category)" to Openting.
Added "Harunal".
Item 4.g Added a new item "Date Passed Generic Fundamentals Examination Section".
Item 12.3 Changed wording to " Certified Startup F.w.
Completed" for clarification.
Item 12.5 Changed wording to " Extra Person On Shift In Control Roca j
(13-week minim a)" for clarification.
Item 12.5a Added a new item " Time On Shift above 20E Power- (6-week
.dnimum>.
Item 14.a Added the words "That Is Based Upon A Systems Aw.vech to Training" for clarification.
Item 15 Added "Dete and Result of Host Recent IBC Administered M=1uication Examination".
Item 19.a Added the wording "I further certify that I have notified.-
my current employer of: (1) all.ptwious employers; (2) any instance where I have been tested by a Health and Human Services (HBS) Certified Drug Testing La 6,., or a Licensee *e testing. facility-for alochol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance where I have been arrested for the sale, use or possession of a ocntrolled substanos described in 10 CFR Part 26; and (4) any reemens for rgmoval or revocation of uneocorted aooses at a nuclear facility".
Item 19.b and Item.19.c Moved 19.b and 19.c tesother. Applicable box.ust now be checked. Also added block for typed name of Training Coordinator and Senior Manap===nt Representative On Site.
PCR NRC USE Under waiver category added " Medical".
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