ML20006D708

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

ML20006D708
Person / Time
Site:	Crane
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Hukill H GENERAL PUBLIC UTILITIES CORP.
References
NUDOCS 9002140276
Download: ML20006D708 (8)

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,lBN 5 1990 Docket No. 50-289 GPU Nuclear Corporation ATTN: Mr. H. D. Hukill Vice President and Director of TMl-1 P. O. Box 480 Middletown, Pennsylvania 17057 i

Gentlemen:'

$UBJECT:

REVISED NRC FORMS 396 AND 398 j

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 t

(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 hava any questions regarding these forms, please contact Richard J.

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

Sincerely, 0?icinni Slened b Robert M. Gallo, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated r

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9002140276 900105 PDR ADOCK 0500 9

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.cc w/o enc 1:

T. G. Broughton, Operations and Maintenance Director, TMI-1 C. W. Smyth, Manager, TMI-1 Licensing R. J. McGoey, Manager, PWR Licensing E.. L. Blake, Jr., Esquire W. Thompson, Manager,OperatorTraining(w/ enclosures)

TMI-Alert (TMIA)

Susquehanna Valley Alliance (SVA)

Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

,J NRC Resident Inspector L

Commonwealth of Pennsylvania bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

DRP Section Chief R. Hernan, PM, NRR J. Dyer, EDO OL Facility Filc RI:D S Gall /

OFFICIAL RECORD COPY lIl ls, i 4 9 A

INSTRUCTlONS FOR ODMPLEYlho IWRC PORM 350 PERBONAL OUALIF6 CATION ST2TEMENT-LICEMBEE T3 CEZAIN VAllD,THis FORM MUST NOT BE ALTERED f

A TYPE OF APPLICAT60N 2.s NEW "X" IF YOl1 ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORlw F.A 'LETELY, FOLLOWING THE INSTRUCTIONS BELOW. THl3 IS TO INCLUDE ALL EDUCATION, TRAINING AND OM.RIENCE THAT YOU HAVE RECElVED UP TO THE DATE OF THIS APPLICAT4ON. NOTE: SEE ITEM F4 - THERL F AN EXCEPTION. ALBO, THis BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "N EW,"

2h thre 2.e-FOR 2h THRU 2.e, COMPLETE E ACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION. TRAINING, AND EXPERIENCE YOU HAVE RECEIVED $1NCE YOUR LAST APPLICATION, NOTE: SEE ITEM f4 - THERE IS AN E XCEPTION.

2.1: RENEWAL "X"IF YOU ARE RENEW,NG CURRENT LICENSE.

2.s UPGRADE

• X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYlNG TO UPGRADE YOUR LICENSE TO A SRO.

2.el MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR F ACILITY AND ARE APPLYlNG 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.

2.f WAIVER REOUESTED "X"THE. APPLICABLE WAIVER REQUESTED AND JUSTlFY 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 08 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 HlGH SCHOOL EDUCATION, FOR MAJOR AREAISI OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PROVIDED FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, OlESEL MECHANIC SCHOOL, ETC.

INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED IF 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 lF YOU NEED FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED, IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR IPTERMITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2. MONTH PERIODI, 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 CANNOT BE DOUBLE COUNTED UN 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 P HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT i

THE PROPORTIONATE AMOUNT OF TIME YOU WERE AS$1GNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD T 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 e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING

' ' t '.

• Z :9CC ;CN NRC FORM 474) OR NRC mr nvy60 SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING Pdo.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 144 AND 14b, THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),

AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED. NEW APPLlCATIONS MUST STILL INCLUDE THE NUM OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY TH NATIONAL NUCLFAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATCRY GulDE 1.B.R3V.2, ARE MET.

15.

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

i 17, COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE A CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TION, 18.

j NRC FORM 396, CERTIFICATION OF MFDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

19.

SIGNATURES - SIGN AND DATE ITEM 10a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SEN MANAGEMENT REPRESENTATIVE ON $1TE.

CETACH THESC ANSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS W8 IORIGINAL AND TWO COPlES EACH PRIATE REGIONAL ADMINISTRATOR.

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16. EXPERIENCE D'ETAILS s Pott 190N TITLE PROM TO

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"18. NRC FORM 388,CERTIFICATIOI.OF MEOlCAL EXAMINATION SY FACILITY LICENSEE,IS ATTACHED ANY F A LSE ST AT EMENT OR GMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS. MAY BElrUBJECT TO CIVIL ANU CRIMIN AL SANCTIONS.

Its, I certity urater penefty of pertory that the antormation in th6 document and ettechmentiis true end correct I further gerhty that I have nottfed my current employer of (1) eh premous ernp4Frers.

(2) eny trictent's wehere i flows tussa teveed by e Heenth end Human Gerytces (HH$) Cettitsed Drug Test 6ng Laboratory or e Licensee's testme tecility for escohus or e control 6ed manetence, and the test resulte tacesiled the autett levels estatihshed pursuv e to to CFR Port 26. (3) any instance evhere I have beers errested for the sale, use or onesession of a controhed substenr a deserthed in 10 CFR Port 26.

b and 14) eny reasone for removel or rewooetion of unsecorted eccess et a nucteer' tactiny, I steo authortre the NRC to submn the results of eneminations to my empsovers for use in propering retreming psogrome, og nessesery.

$10NAT URE-APPLICANT DATE CHECK APPLICABLE BOX

b. I certify that the etsove named 6ndowHull has successfully completed the facihty licensees requerementt to be hcensed as en Operator /Sertor Operefor pursuant to T6tle 10. Code of Federal Regutelions.

Port $4;enti titet the indhrkhsel has a need ter en Operator /Serieor Operefor lit nee to pertorm hes/her eseagned outses and thet the W" al# be meGe swetleben for eneminetson. I eleo certtty under m

genemy of perjury thet the information ln th*t document and ettechmente is true evid ea rect Y

sk R$NEW AL ONLY - I certify that the above named Indrstdual meste tfw approwd requedfecaison program (wien emesordont noced m trem f h as required by section 60.b4 ti-1) of 10 CF R 60. entf that hohhe has discharged h6s/her licensed responstoilniet competently and estely I ateo teritty under penetty of pertury that the 6ntormation ln this document enriettechments f

to true cred correct TRAINING COORDINATOR l

SENIOR MANAGEMENT Rf PRESENTATIVE ON SITE PRINTED OR 7YPED feAME PRINTED OR TYPED NAME M___

SIONATURE DATE SIGN ATUR E lDATE FOR NRC USE E

W AIVER (Check or Opmpfere trems. es appl #cabJe) l MEETS REQUIREMENTS l l DOES NOT MEET REQUIREMENTS (fotern oefowl c,,,,,,,,

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WRITTEN OPE R ATING ELIGIBILITY MEDICAL sicNATURf R E VIEVv f H DATE OTPER I

1 NRC 70AM 395 (10891 l

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NRCHiRuJB4 W S. NUCLE AA it &ULATO.1Y COMuitst&N a.removeo e,v ove No 3: 2 0024 II 'M f lo sel e

10 Cra tl 23. 68 4

• E8?iMAft0 SURDIN PER R E FONSE TO Cots *Lv WITH TMat #N POmu A f som LOL L ECT TON meoursT-75 usis esul t4 47 CEWACATION OF MEDICAL EXAMINATION qqo,,c,cgaay,La',o,,^ao;gogy,=

smANCH iP 43ol. U$ NUCitAR RE Qut.AT OR Y COesMab BY FAClg ggegg

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• AsusNOTom oc 20603 NAME OF #FUCANT F ACILIT Y ActLITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CER '

I TAT ?HE ABOVE NAMED APPLl". ANT FOR AN OPE RATOR' SENIOR OPERATOR LICENSE HAS BEEN E KAMINED BY A PHYSICIAN NIN T E D N AME (of shyssesen) lST ATE AND LICENSE NUMBER l E K AMIP4ATION DATE BASED ON THE RESULTS OF THE E XAMINAllON INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENEP AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE RATION AL ERRORS ENDANGERING PUBLIC HE ALTH AND SAFETY. I CERTIFY THAT les RE ACHING THis DETERMINATION. THE GUIDANCF CONT AINED IN ANSl/ANS 3 41983.OR ANSI /ANS16 41977 (N3901 W AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW 8V NRC.

ON THE BASIS OF THE RECOMMENDATION OF TM,fHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO RESTRICTIONS

2. CORRECYlvE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES

3. HE ARING AfD BE WORN WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICENSE OR E XCEPTION Provide oetails below anri attaen supporting medical evidence for NRC review.

6 REST RICTION CHANGE F ROM PRE VIOUS $UBMtTT AL. Provide omails below and attach supportme medicat ewiden~ for NRC review PHOPOSED WORDING OF RESTRICTION (Stara 4 aoover l

KE LATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION (Srse/ty mdscare how restracree ws/lcorrect the desqusMyrna condirenJ RE MARKS FO 9 RESTRICTION CHANGE (Stoca S acovel B. NONMLDICAL CERIIFICATION POWE R ftE ACTORS-THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' AND FITNESS FOR DUTY REOUtREMENTS OF THl$ F ACILITY FOR LICENSED OPE R ATORS.

NON-POWER RE ACTORS.

THIS CERTIFIES THAT THE APPLtCANT HAS BEEN FOUND TO MEEi THE SAFEGUARDS' REQUIREMENTS OF THis F ACILITY FOR LICENSED OPER ATORS. AND 4 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBST ANCES AS ESTABLISHED PURSUANT TO 10 CFR 26.

a.uv e ALse. s t e r suamr on owissioN sN tais oucuuen t iNctuoima Ar r AcwwtNis uAv et susatcr ro ctvit Aso cniusNAL pNcriums. i ctH vie r unutn etna 6 t v u*

IGRJURY THAT TH4 INeORMATION IN THIS OOCUMENT AND ATT ACHMetiT5 is TRut AND CORRECT.

blNTED N AME AND SIGNATURE (Samor Marwgement Representarsve on 5,re; TITLE DATE in accorcance witn 10 CF R 55.5. Commumcations. this form shall be suomitted to the NRC as tonows: SY MAIL ADDRESSED 10:

Regional Administrator. Region 1 Regional Administrator. Reg on il Regional Administrator. Region til U.S. Nuclear Regulatory Commisuon U.S. Nuclear ReWatory Commiseen U.S. Nuclear Requistory Commassen 475 Allenmie Road 101 Marietta Street. Suite 3100 799 Rooseveit Road Kmq of Prugua PA 19406 Atlanta G A 30323 Glen Enyn. IL 60137 Regenal Admsnistrator. Region IV Regenal Admmistrator, Region V U.S. Nuclear Regulatory Commissen U S. Nuclear Requietory Commenen 611 Ryan Piaae Drive Suite 1000 1450 Wria Lane. Suite 210 Arimgton. Tx 76011 Wamut Creen. CA 94596 PRiv ACY ACT STATEMENT Pursuant to 5 U.S.C. 552aleH3), enacted into law by wetion 3 of the Pr.vacy Act of ROUTINE USES The information may be disclosed to an aoorooriate Feoeral. S: ate. or 1974 (Public Law 93579), the followmq statement is urmsned to moividuais ano local agency in the event the mformation indicates a viceation or poter'tial violation of law r

supply mformaten to the U.S Nuclear Regulatory Commission on NRC Form 396. and m the event tne information moscates a violation or oorent,at noitten of law and m

. This mformat on is mamtained m a system of records designated as NRC 16 and the course of an comimstratnie or luuicial proceedmq In addition. th.s information may be described at 51 Federal Regitter 33157 ISeptemt* 18.1986).

transferred to an aoproonate Federal. State. and locai agency to the entent reievant and AUTHORITY: Sectens 107 and 161td of the Atomic Energy Act of 1954. as neceuary for an NRC decision acout you.

amended t42 U S.C. 2137 and 2201(d).

WHETHER DISCLOSUhE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISL Information entered on tnis form is used to aetermme INDIVIDUAL OF NOT PROVIDING INFORMATION. Disclosure s vosuntary. If tne whether tne pnysical condition and generat heatth of the appticant are such tnat they mluested mformation is not provided no*ever. tne aporcation for a facility operator s will not cause operationes errors endangermg puolic health and safety. This mforma oc senior operator s incense may be ceneed tion may be used by the NRC staH to determine if he irutiwduai meets the require-SYSTEM MANAGERISI AND ADDRESS Ch4ef. Operator Licenung Branen. Ottice of t

monts of 10 CF R 55 to tame en esammation or to be issued an operator's license Nucle.r Reactor Regulation. U S. Nucjear Regulatory Commisuon. Washmqton OC 20555. !

J Nec eqau met. qmin

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ENCLC60RE 3 t

SIRE %RY OF QMN3ES 'IO tmC PollM 396 L

Medical N-4mtion Certification Added block "flestriction Osange From Prwious Sukmittal" plus Remarts

section, l

Non-Medical Certification Changed non-medical certification statement to: Peuer Beactors-This certifies that the applicant has been found to meet the safeguards' and fitnoes for chzty requirements of this this facility for licensed operators.

Henpower 'Ihis certifies that the applicant has hamn found to meet the safesuards' requirements of this facility for licensed operators and I have no knowledge of the applicant

--==44ne the cutoff levels for alcohol or controlled substana== as es+=h14=h=4 pursuant to 10 CFR 26.

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t EMCLDSURE 4 SUtttARY OF CHAN3ES 10 IEC POEM 396 a

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

t Item 4.f

- Added "(Categorr)" to Operating.

Add _ed "tiaMn=1".

.t Item 4.g Added a new item "Date Passed Generic Fundamentals Examination Section".

.s Item 12.3 Changed woniing to " Certified Starup ".4.

Completed" for clarification.

Item 12.5 Changed woniing to " Extra Person On Shift In Control Room (13-week minimun)" for clarification.

1 Item 12.5a Added a new item " Time & Shift above 205 Power (6-week minimum)a, Item 14.a Added the words "That Is Based Upon A 3ystems Arproach to Training" for clarification.

Item 15 Added "Date and Beault of Most Beaunt HilC Administered Bequalification Examination".

Item 19.a Added the wortiing "I further certify that I have notified ur current employer of: (1) all previous employers; (2) anr-instance whern I have been tested br a Health and Husen Services (HilB) Certified Drug Testing Laboratory or a Licensee's testing facility for alochol or a controlled

. substance, and the test results e the cutoff levels established pursuant to-10 CFR Part.o6; (3) any instance L

where I have been arrested-for the sale, use or possession.

of a controlled substance described in 10 CFR Part 26; and (4) any reasons for 24moval or rWUccation of unescortei acones at a nuclear facility".

Item 19.b and Item 19.c Moved'19.b and 19.c together. Applicable box aust now be checked. Also added block for typed name of Training l-Coortiinator and Senior Management Representative & Site.

L PGt NIC USE muler waiver category added "tenni:nal".

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