ML20006D699

Forwards Revised NRC Forms 396 & 398,certification of Medical Exam & Personal Qualifications Statement, Respectively

ML20006D699
Person / Time
Site:	Calvert Cliffs
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Creel G BALTIMORE GAS & ELECTRIC CO.
References
NUDOCS 9002140266
Download: ML20006D699 (8)

Text

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5 1990

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, TAN w-I Docket No. 50-317' 50-318 t

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l Baltimore Gas and Electric Company l

-ATTN: Mr. George C. Creel Vice President Nuclear Energy Calvert Cliffs Nuclear Power Plant M0 Rts 2 & 4, P.O. Box 1535 t

-Lusby,' Maryland 20657 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..

LAll 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.-

EThe enclosed applications are for your use. Additional. copies:can be obtained by contacting Beverly Martin,'U.S. Nuclear Regulatory Commission, by telephone l(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.~

r If;you have any questions regarding these forms, please contact Richard J.

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

Sincerely, Criginni Signed ByI

Robert M. Gallo, Chief h;

Operations Branch Division of. Reactor Safety 7

Enclosures:

As stated

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W. J. Lippold, General Supervisor, Technical Services Engineering T. Magette, Administrator, Nuclear Evaluations J. Lemons, Manager, Nuclear Outage Management L. Russell, Manager, Calvert Cliffs Nuclear Power Plant J. Walter, Engineering Division, Public Service Commission of Maryland J. Hill, Supervisor, Operations Training (w/ enclosures.)

Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector State of Maryland (2) bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

J. Wiggins, DRP L. Tripp, DRP D. Limroth, DRP K. Lathrop, DRP S. McNeil, NRR J. Dyer, EDO OL Facility File Gallo/pb 01/02/90 l

0FFICIAL RECORD COPY 396 & 398 FORMS - 0016.0.0 12/14/89 A

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INSTRUCTIONS F3D ODMPLETING NIC P3RM 308 ^

PERSONAL C UALIFICATION STATEMENT-LICENBEE i,

TO REMAIN VALID,THIS F07.M MUST NOT BE ALTERED 14 TYPE OF APPLICATION -

2.e NEW "X" lF 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 YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICAT40N, 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 "N EW."

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 EXCEPTION.

2.b RENEWAL "X"IF 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 SHO, 2.d MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT, 2.s REAPPLICATION "X"IF YOU HAVE PFEVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAIVER REQUESTED "X"THLAPPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

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

THl3 IS NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.

TlON SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFESWAS 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 LICEN6E. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS, 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAIJTECHNICAL 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 VOCATlONAL/ 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 CERTiflCATE OR DEGREE WAS AWARDED, IF ADDl-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 SPEN 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 SPCNT IN FULL-TIME TRAINING TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13),

ALL REQUALIFICATION TRAINING TIME IS 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, 13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR EACH POSITIO

- HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME.15 YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE AS$1GNED 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 e. GR ADUATE OF INPO ACCREDITED OPERATOR TRAINING PRO AND b. CERTIFIED f 0N NAC FOPY 4741 OR MRC APPROVED CIMULATION l' ACILITY 13 USED IN THE OFERATOR TMmlNG PHO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 142 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 BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.B, 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 REQUALIFICATION EXAM

NATION, 16.

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 (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 AP 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. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIO MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUSMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EACH) TO PRIATE REGIONAL ADMINISTRATOR

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. t CP A 46.31 96.35, 95.47,ensI D617 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH TH18 INFORMAf TON COLLECTION REOUEST: 2D HRR.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE INFORMATION AND RECORDS MANAGEMENT

$ RANCH IP-530). U.S. IdUCLEAR REOULATORY COMMIS.

SiON. WASHINGTON. DC 20566. AND TO THE PAPERWORK REDUCTION PROJECT (31604000). OFFICE OF MANAGE.

TO REMAIN VALID,THis FORM MUST NOT BE ALTERED MENT AND DVDOET, W ASH!NOTON, DC 20603.

1. APPLICANT'S FULL NAMf (Last, first, Midtfief AND ADDRESS (actudel/P Cbdt)

4. TYPE OF APPLICATION (ChacA app /rable bones /

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1. HOT t RE APPLIC ATION

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3. BIRTH DATE

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g. DATE PASSED OENERIC FUNDA.

MM YY MENT ALS E X AMIN ATION SECTION

6. OTHER ISanct&l l

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(19 AM*LICABLES

5. TYPE OF LICENSE APPLtED FOR

6. PREVIOUS LICENSEls) HE LD a OPERATOR

e. DOCKET NUMBER RO SRO b. LICENSE NUMBER

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7.NAME AND ADDRESS (Inch /el/PCbdelOF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT F ACILITY

a. PLANT SUPERINTENDENT 6 AUnlLIARY UNIT OPER.

ATOR/ TRAINEE.TURetNE

& ASSISTANT PLANT SUPERINTENDENT BUILDING / EQUIPMENT OPE R ATOR (NON t FCENS.

s. SH8FT SUPERVISOR (O OPERA FOR/

4 STAFF ENGINEER 1 OTHER($asci4) a SHIFT TECHNICAL ADVtSOR/ SHIFT ENGINEER

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lF ACILITY DOCKET NUMBER

8. NAME OP APPLICANT'S F ACILITY f, INSTRUCTOR

9. ADDITIONAL F ACILIT Y DOCKE TS IMuers-ome !,dcensess

s. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERaFOR i

11. EDUCATION g HIGHSCHOOL

s. MAJOR AREA 181 OF STUDY t.7*!!.

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DEGREE CODES

d. VOCATIONAL / TECHNICAL f $g7,$N

, ves op t ea,%i%o MONTHS QRADUATE ENGINE E RINO (Fift031 VES NO npon p Ggggagege,nedJ OED EQUlVALENCY OTHER RTIFICATE 2 ASSOCIATE I

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3. BACHELOR b NUMBEM Op

4. M AST E R VEARSOF

6. DOCTOR AL COLLEGE

2. T R AININO (SINCE LAST APPLICATION - SEE INSTRUCTIONSI

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

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3. gwS/PPwS 08SERVATION

4. ERS/CRMI 1

3-OPERATING PR ACTICE 5.OTHER Ispec,41 CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING IsacAnses Csess,oems FOSStL

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SIMULATOR NAMES

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COMMERCIAL NUCLEAR (inesudsne Reseeren/rese Reactors 4 -SRO INSTRUCTION 10 REACTOR OPERATOR (trensed; 6 - ff$,^r'g'E*,"u,E'" ' "* ' " ' " ' "" "

11. SENIOR OPERATOR (twennet a.[$'gfa"r4# N Ud M '0**"'

12. SHIFT SUPERVISOR (then ds j

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6 -REQUALIFICATION

13. STAFF /SHIF T ENGINEER (tkensed) 7 -OTHER (sese,47

14. AUXJEQUIP. OPE RATOR INoniernsed)

15. PLANT ST AF F

16. OTHE R (spect&J NRC PORM 300 (1040)

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14. FACILITY OPERATOR TRAININ2 PROGRA*2

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TRA100000G PROGRAan TMAT SA 0ASED UPON A.

YES NO CEA TJF#CA TION"103 NRC i.PPROYED SIMULATBON.

YES NO

/ SVTTGAd8 APPROACN10 TRAteetteG blT IS USED IN THE OPERATOR TRAINING g

15. FOR RENEWALS ONLY

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b. DATE AND RESULT DF MOST D*T' "E8UL' l-NDune OPER ATED F ACILITYr RECENT NRC ADMINISTERED pggg pgg,

REQUALIFICATION EKAMINATION

16. EXPERIENCE DETAILS

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6. F ACILITV

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17. C00 AGENTS dasse#9 ene seem neer so wnNe yo. eve

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18. NRC PORM 308, CERTIFICATION OF MEDICAL EXAMINATION SY F ACILITY LICENSEE,18 ATTACHED ANY FA'.SE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUIUECT TO CIVIL AND CRIMINAL SANCTIONS.

see. I sentfy unseer pensay of periury thei the informenton in shie document and etsschmente is true end corvoet. I further certify ther I neve noter ed my eurveat eminever of: It } est inrovious entwayers:-

62) any leugense ashore i hem heen tested by e Hemath enel Hymen Serw6ees (HMS) Cer16 feed Drue Te ating Lenoretary or e Licename seeune seemedad the autoff esuees ense6lehed pursuant to 10 CPR Port 28;13) eny enmente wohese I have been arvened for the sets,'s testune facinty for escohol or a controleed numene use or posessmen el e comroned subetones eastethod in 10 CF A Port 26; '

and tel any resenne ser rumount er rewoesinon of unsecorted accese et a nuenseritectiny, 8 eten authorhe the NRC to submn the reeuits el enerrunettsag to my emeWoyers ter bee en propertn$ retreimag inessant, as nuesmery 84000ATURE-APPLMANT parg CHECK APPLICA9LE SOX

] k i sortefy that the show named indiwWiuol hee saceessfuHy compaeted the fecRNy treneses requirememe to be hcensed as on Operator /

.f ese of Fedured Reguistene, Part OS:see that the endswedues hos a need for en Ooorstoriesneer Osorsior itsenes to perform his/her ses pied duiese end that the h -a* ce made ove6asswo for esen pennety of portury that the informaten ln thee document end attachmente is true and sorrect.

a ReiNEW AL ONLY - I certify that the above named individual meste the approwd requelification progrern (wirA esceordone opfvelin from f/J ps required by esetton 50,54161) of to CFR 50. and it.et he/she hee ditcherged h6e/her hcensed responesbitntes competently and esfely, I esso certify under pensity of pertury that the intormation in thne encument and ettechenents -

le true and correct.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE -

PRINTED OR TYPED NAME PRINTED OR TYPEO NAME i

lDATE SiO86ATURE lDATE SIGN ATUR E e,

FOR NRC USE WAIVER (Check or Complete items, as applicable) -

l MEETS REQUIREMENTS l l DOES NOT MEET REQUIREMENTS theseht eebw onanveo av osmso ey CATEGORY Ha anovan t e ns necio%

Hv aoov a n T E ns p r o t on WRITTEN OPERATING -

ELIGISILITY MEDICAL SIGNATURE-REVIEWER DATE OTHER-l

. NRC FORed JOS 110801 --

e U.S MUCLE AW t.E EULATOAV COMMIS4 ION teemovi.o ev oM.e NO J:300o24

'pe8,1C,sOnJ 26 uut talAs tiCFR H 22,H 27 asTIMaff0 SumotN ptR m e SPONsg to courgy seggw ens ee.47 TMit iN80mMAf soas (,OL L t ct ion manute? 7s Mag CERTIFICATION OF MEDICAL EXAMINATION gago,l,y4yj,,,a'a',ao;;govaog,g,ig smANCH 19 4 301 US NUCLEAR REGULATORY COesM4

' BY FAClg gggg h

SiON.

• A$NINGTON DC 2o654 AND TO THE D APtRyeDmK mg DUCTION Ws0 JECT (Jit040241 08pict OF MANAGE.

MENT AND OUDGET, Wt ASHi*sGTON DC 20003 NAME OF APPLICANT t_.

F ACILITY l F ACILITY OOCKET NUtegE R A. MEDICAL E XAMIN ATION CERTIFICATION THIS IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR! SENIOR OPE RATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.

P41NTED NAME totphysrcrans l STATE AND LICENSE NUMBER l E XAMINATION OATE SMED ON THE RESULTS OF THE EXAMINATION INCLUDING INFORMATION FURNISHED BY Tele APPLICANT. THE PHYSiCI AN HAS DETERMINED TH AT THE APPLICANT'S PHYSICAL CONDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MiGHT CAUSE OPER ATIONAL ERRORS ENDANGERING PUSLIC HEALTH AND SAF ETY. I CE RTIFY THAT IN RE ACHING THIS DETERMINATION. THE GUIDANCE CONT AINED IN ANSI /ANS 3 41983.OR ANSI /ANS 16 4-1977 IN3801 W AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.

ON THE BAS 15 OF THE RECOMMENDATION OF T4MHYSICIAN I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

l 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 details below and attach supportmg medical evidence for NRC review 6 RESTRICTION CHANGE F ROM PRE VIOUS SUBMITTAL. Provide deia es betow and attach suponr1mg medical eveence for NRC revww PAOPOSED WORDING OF RESTRICTION (Slack 4 acovel tie LATIONSHIP OF REST RICTION TO DISOUALIF YING CONDITION (8reny endecere how retrncren wellcortver the desquetttymg conurrenJ KEMARKS FOfl RESTRICTION CHANGE (8/ock 5 400,91

8. NONMEDICAL CERTIFICATION POWE R RE ACTORS 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.

NOM POWE R RE ACTOR $.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPER ATORS. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT E XCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 i

(NY F AL5t St A rEMENT OM OMI5340N epe rMIS DOCUMENT INCLUDINu art ACMMtN T5 M AV 0t SuSJEC r rQ CivsL AND (.HiMiNAL SANCiiONS. t CtH ilP r UNutH PtNALi v UP FtRJUR Y 1 HAT THE IN80RMAflON sh THIS 00CUMENT ANO ATT ACMMENTS 15 TRut ANO CORRICT.

lDATE PAIN TED NAME AND SIGNATURE (Sener Marugement Neorewnrarsve on Sites TliLE in accordance niin 10 CF R 55.5. Comraunications, this form shall be suornetted to the NRC as follows; BY Mall ADDRESSED TO:

Regional Admsnistrate,r. Region i Regional Administrator. Regen ll Regional Admmistrator Regeon til U.S. Nuclear Regulatory Commissen U S. Nuctur Rewiatory Commission U S Nuclur Rewiaiory Commissen 475 Allendale Road 101 Manetta Stent. Surte 3100 799 Roosevelt Road Kmg of Prussia. PA 19406 Atlanta GA 30323 Glen Ellyn. IL 60137 Regenal Adme.nstrator. Region IV Regenal Admmistrator. Region V U.S. Nuclear Regulatory Commission U S. Nuciear Regulatory Commissen 611 Ryan Plaae Drive. Suite 1000 1450 Maria Lane. Suite 210 Arlingecq, TX 76011 Walnut Crun, CA 94596 PRIVACY ACT STATEMENT Pursuant to 6 U.S.C. 552atell31. en cted mio law by section 3 of the Pnvacy Act of ROUTINE USES: The mformaten may be disclosed to an appropriate Federal. State, of 1974 (Pubhe Law 91 6791, the followmq statement is uremhed to mrtivirtuais who local agency m the event the mformation md. cates a violation or potentian violation of law r

suppty informaten to the U.S. Nuclear Regulatory Commission on NRC Form 396 and m the event the mformaten mo cates a viol <iten or potential violation of law and in This informaten is wntained m a system of ee: mads designated as NRC 16 and the course of an admemstrative or tudicias proceedmg in addition, th.s mformation may be described at 51 Federal Register 33157 (September 18,1986L transferred to an appropriate Federal. State. and local agency to the entent remvant and AUTHORITY: Sections 107 and 16)(i) of the Atomic Energy Act of 1954. as necessary for an NRC decision sbout you.

ameaded 142 0 SsC. 2137 and 220lbt).

WHETHER DISCLOSURE IS MANDATORY OR v0LUNTARY AND EFFECT ON PRINCIPAL PURPOSE (SL information entered on this form is used to determme INDivlDUAL OF NOT PROVIDING iNFORMATION Disclosure is voluntary, if the enether the privsical conditen and genersl health of the applicant are such enat they requested mformation is rmt provided, however. the application for a facility operator's will not cause operational erfors endangering puOl6C health and safety. This informa. or serttof operator's license may be demed II)n may be used by the NRC uaff to determene if the mdividua6 meets tne recurre SYSTEM MANAGERISI ANO ADORESS Chief. Operator L.censirig Branch Office of nwnts of 10 CF R 55 to taae an eneminaten or to be issued an operator s hcense Nuclur Reactor Regulation. U.S. Nuctur Requiatory Commission. Washmgton, DC 20555 NnC sopM 3en 'to49

l IINC1460RI 3 SM1ARY OF CHANGES '!O 19C POEM 396 Medical Examination Certificatica Added block " Restriction Change Fate Pzwicus Suhaittal" plus Remarks eaction.

Non-Medical Certification Changed non-==44=1 oortificatien statement to: Pcwer Reactors-This certifies that the applicant has been l

~

found to amet the safeguards

• and fitness for durty rwauirements of this this facility for licensed operators.

Nonpower-This certifies that the l

applicant has been found to meet the L

safeguards' requirements of this I

facility for 14aan==4 operators and l

I have no knowledge of the applicant -

==a==44ng the cultoff levels for alcohol l

or controlled substances as es+=h14=h=4 t

pursuant to 10 CFR 26.

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r 74 I

.y.:

EHCLDSURE 4 SUttERY OF CHAIME 'to NBC FOIH 396 t

Itas 4.d Added clarifying statement to indicate this is to be checked only if application is to ammad license to add additional unit (s).

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

Added "PleMnal".

i Itan 4.s Added a new item "Date Passed Generic Fundamentals Examination Section".

Item 12.3 Changed wording to " Certified Startup L4 Completed" for clarification.

l t

Item 12.5 mansed wording to " Extra Person % Shift In Control Room (13-week minina)" for clarification.

Item 12.5a Added a new item " Time h Shift Above 20E Pcuer (6-week minima)".

Item 14.a Added the words "'! hat Is Bened Upon A Systems hvech to Training" for clarification..

Item 15 Added "Date and Beault of Most Roosnt NBC Administered P-=1 Hination ltusmination". -

L

. Item 19.a Added the wording "I further certify that I have notified my current esplayer of: (1) all previous easiloyers;' (2) any instance where I have been tested by a Health and Human Servions (HHB) Certified Dnas Testing LEL.wi or a Licensee's testing facility for alnahal or a cen+relled substance, and the test results M 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 controlled substanos described in 10 CFR Part 26; and.

(4) any twesons for removal or rvvocation of unescorted access at a nuclear facility".

. Item 19.b and Item 19.c Moved 19.b and 19.c tesether. Applicable box aust now be checked. Also added block for typed name of Training Coordinator and Senior Manarament Representative m Site.

POR NRC USE Under waiver category added "!8aMnal".

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