ML20006D712

Forwards Revised Forms 398 & 396 Re Personal Qualifications Statement & Certification of Medical Exam by Facility Licensee,Respectively.All Applications for Licenses to Be Submitted on Revised Forms by 900201

ML20006D712
Person / Time
Site:	Yankee Rowe
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Kadak A YANKEE ATOMIC ELECTRIC CO.
References
NUDOCS 9002140282
Download: ML20006D712 (8)

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i JAN 5 1990 m

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Docket No. 50-29 j)

Yankee Atomic Electric Company ATTN:. Dr. Andrew C. Kadak k,

-President and' Chief Operating Officer

~580 Main Street:

Bolton, Massachusetts 01740-1398 1

Gentlemen:

SUBJECT:

REVISED NRC' FORMS 396 AND 398 a

Enclosed is alcopy of the revised NRC Form-398'(Enclosure.1), Personal Qualifications? Statement - Licensee and revised.'NRC. Form-396-(Enclosure 2),

1 Certification:of. Medical Examination By~Facili.ty Licensee.

i

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

Changes to-NRC.

Form-398 are' detailed in Enclosure'4.

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. All applications for' licenses are to be submitted on these revised forms no

1ater than February 1, ~ 1990.

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' The 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; NuclearLRegulatory. Commission,

'Information and Records Management Branch,l Mail Stop NMBB 7714, Washington, D.C.'

20555.

'If)you-have any questions regarding:these forms, please contact Richard J.

l

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

Sincerely,

'CriginR1 Signed By:

i Robert M. Gallo, Chief Operations Branch Division =of Reactor Safety o

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Enclosures:

As stated 4

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L OFFICIAL RECORD COPY 396 & 398 FORMS - 0031.0.0 12/14/89 y

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Yankee Atnmic: Electric Company 2

cc'w/o. enc 1:.

N. St. Laurent, Plant Superintendent G. Papanic, Jr., Senior Project Engineer - Licensing

,R. Hallisey, Dept. of Public Health, Commonwealth of Massachusetts C. Russell = Clark, Training Manager (w/ enclosures)

Public Document Room (PDR)

, local Public Document Room (LPDR)

,c Nuclear Safety Information Center (NSIC)

.NRC Resident Inspector Commonwealth of Massachusetts, SLO Designee

State of-Vermont,. SLO Designee -

bec w/o enc 1:

Region;I Docket Poom (with concurrences)

M.< Perkins,LDRMA (w/o enc 1)

R.-Blough, DRP H. Eichenholz, SRI - Yankee (w/ concurrences)

G.". Grant; SRI - Vermont 1 Yankee M.-Fairtile, NRR J.iJohnson, DRP'

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! 4 9 0FFICIAL RECORD COPY 396 & 398 FORMS - 0032.0.0 12/14/89 4t>

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. INSTZUCTIONil FOR 00MPLETING NRC FORM 308 PERSONAL C UALIFICATION STATEMENT-LICENSEE TO REMAIN VALID,THIS FCT.M MUST NOT BE ALTERED 4 ' TYPE CF APPLICATION 2.e NEW "X" IF 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 RECElVED UP TO THE DATE OF THIS APPLICATION. NOTE: SEE / TEM 74 - THERE IS AN EXCEPTION, ALSO, THIS,

f BLOCK IS TO BE MARKED lF PREVIOUS NEW APPLICATION WAS WITHDRPL. 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 RECEIVJD SINCE YOUR LAST APPLICATION, NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION.

2.b RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE 2.c UPGRADE "X"IF 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 YOU'R 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 REAPPLYlNG.

2.f WAlVER REQUESTED "X"THE. APPLICABLE WAIVER REQUESTED AND JUSTlFY IN COMMENTS SECTION (ITEM 17),

2.g 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 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 LICENSE. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION FOR MA 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 DEGREE WAS AWARD TlONAL $ PACE 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. T 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 W 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 SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED EXPERIENCE (ITEM 13).

ALL REQUALIFICATION TR AINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM, PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDEH 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 HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT l

THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SH NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT AR TIME PERIOD.

14 FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRA AND b. CERTIFIED (ON NRC FORM C': " ""C /.TT.".CWD SIMULATION FACILITY IS USED IN THE OFERATOR TRAIN 1NG PRO-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 NU OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULAT l

GUIDE 1.8, HEV. 2, ARE MET.

1 FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSU 15.

LICENSE lF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION

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, l

ATTACH ADDITIONAL INFORMATION.

17 COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON 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.

I 19.

SIGNATURES - SIGN AND DATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOU MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EACH PRIATE REGIONAL ADMINISTRATOR.

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W PORM,85 U.&, wuCLEAa LEEULAT04Y COamslasloel APPIOVED BY Oess: NO. 31604090 cATERiCElvfD my gy-E RPIRE S. 149 42 N8 J 88"'""* MEI (gN,.se mb es EETiMATEo eURoEN PER RESPONSE To COMPLv WiTH TH18 INFORMATION COLLE JTION FtEQUElr( 2D ffRS.

FORWARD COMMENT 8 REGARDING BURDI.N E STIM AT E PERSONAL QUALIFICATION STATEMENT-LICENSEE TO TH$ (NFORMATON AND R& CORDS MANAGEMENT DRANCH (*406, U S. DeUCLE AR REGULATORY COMM IS-EION, WASHitc3 TON. DC 20lbu, AND 10 THE f 4PERwoRet REDUCTION PROJECT (J1600090), OMICE Ur MANAGE-TO REMAIN VALID,THl3 FORM MUST NOT BE ALTERED MENT AND SUDOCT, W ASHINGTON, DC 20603.

1. APPLICANT *S FULL NAME (Lest. First, Mnid/el AND ADDRESS (sclude //P Cbdel 4, TYPE OF APPLICATION (Check app /raf>/e bonest

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2. COLD 1 FIRST WlWENICowJ

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13. RENEWAL 3 THrRD M

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3. E LIOltiLIT Y G. MULT1. UNIT lA40lNO TOINCLUDE ADDITIONAL 4 + MEDs*,AL

2. CITIZE NSHIP

3. BIRTH DATE VNIT) 6 OTHER 6 UNITED STATES MONTH DAY YEAR

g. DATE PASSED GENERIC FUNDA.

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MENT ALS E X AMIN ATION $ECTION l

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6. TYPE OF LICENSC APPLIED FOR

6. PREVIOUS LICENSE (5) HELD -

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d. F ACILITY DUCKET NUMSER k SENIOR OPERATOR I

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7. NAME AND ADDRESS (Include 2/P Codel OF APPLICAN05 EMPLOYE R

10. CURRENT POSITSON AT F ACILITY I

a. PLANT SUPERINTENDENT L AU11LIARY UNIT OPtR.

ATOR/TRAINE E/TURE INE k AS$18 TANT PLANT SUPERINTENDENT BUILDING / EQUIPMENT OPER ATOR INON LICilJ5

a. SHIFT 8UPERVISOR '

IO OPf 4A TO4) sL STAFF ENGINEER

1. O THER (Speci4) lF ACILITY DOCKET NUMBER e, SHIFT TECHNtCAL ADVISOR /5HIFT ENGINEER i

3. NJ.Mt OF APPtl CANT 5 F ACILITY l

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9. ADDITIONAL F ACILITY DOCKETS (Afusrewast Leenaesi

e. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPER ATOR

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s. MAJOR ARE Aisl CF STUDY

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13. E XPE RilNCE (DO NO T DOUBLE COUNT-SEE INSTRUCTIONS)

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1 RO 2 -PLANT SYSTEMS 2 EOOW/PPWO CLASSROOM a. EWS/PPWS OBSERVATION 4. E RS/CRW 3-OPERATINO PRACTICE 5 OTHERIsam4A CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING (inesweee Cuwoom)

FOS $1L 6 OPERATOR SIMULATOR NAMES

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11 SENIOR OPER ATOR (tecenant>

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12 SHIFT SUPERVISOR tticennds

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6 -R EQUALIFICATION 13 STAFF / SHIFT ENGINEER Itscensed/

7 -OTHE R issec147 14. AUXJEQUIP, OPE R ATOR INon/scened) 15 PLANT STAFF 16 OTHER(specs &s NRC FORjf 398 Hose?

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18. NRC PohM 306 CERTIFICATION OF MEDICAL EXAMINAT;ON BY FACILITY LICENSEE;IS ATTACHED l

ANY F ALSE STATEMENT OR O*11SSION lN THIS DOCUiMNT. INCLUNNG ATTACHMENTS. MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

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h - 6 earthy under penehy of pertury thrt the informetton tre :his tsacument and attachenerits is true and sortect, i furthw settify that ilieve notifdd my current employer of: (1) all prewtous encloyers; (2) any instance tellere I have imen totied thy a Hesttn and Human Smeses IMH3) Cenifled Drup Testine Latich etory or e Licensee's testing factiety for escohol or e sontrobed euhotence. and tite test

eewne acessmed ene es;ott leven estenhshed pursuant to 10 CPR Port 28

13) any instance e here I how teneurremed for the sese, use or possession of a contmiled autisiew insurrit.ed an 10 CFR Port 26;

. and (41 eny resecas for remomet or fetoestton of unes:Orted steens at a nueteorideaility, i eleo authort-e tie NRC to tutimW the results 99 enemnetens to my err.peoyers for x1 en propering retrennmg penoienw. es t asemary.

SiO61ATURE-APPLICANT DATE l'i h

RHECK APPLICABLE SCX l h 6 ermify that the emme aanwd ladividual has sucteufupy earnplated the lackhty licement req em9me 4 te beennes as en Operator /sener Operator pursuant to Title 10. Cods of Federal Resu.etens,

===J Port to: ens enet the indMehsel he e nmd for en operetorItener %sator imenee to pertem en/per essesned sunes and that thuh mill te mese setights for esaminster, i also certify unter -

- penemy of pot ry inet the informeten e the teaunwni and attactments a true and sorrect.

l. & RENE% AL OalLY - I rerufy that t,he show named ind.v6 duel mers se soproved erfluellfication program (with encerMne nosed h from f 71 es require

-s 1 t%et ne/she >= d*he@ his/her licensed respon:Lbilities sote@Pteneey and tofefy.1 sito eefttfy under penettV of perjury that the informetton in this document end attetements,

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is true sna eormt.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATivi ON SITE PftlNTED ON T YPED NAFE -

PR:NTED OR TYPED NAME 9

lDATE SIGr[ATURE

$1GNATURE DATE FOR NRC USE 4'IAIVER / Check or Cbmplete /tems, as matice64) l ME ET$ REQUIREMENTS l l DOES NOT MEET REQUIREMENTS (soisda cemw

- CATEcoRy D'"D" HE ADQu AnTEP9 R t GION e4E ADC4U AR T E RS R E GiON WRITTEN OPERATING ELIGIBILITY MEDICAL SIGNATURE REylEveER DATE OTHER feRC PORM 30011049),

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$5TIMatt0 SUffDIN Pelt Respoessa to courgy evifN ene 96.87 TMfS imeOPM A T10ai LOL L tcTion atoutpT-29 Mfta CERTIFICATION OF MEDICAL EXAMINATION gngo,g,y,LR*o,A,aogog, *,g ORANCH iP 4Jol. U$ NUCLEAR HEQULATDRy COndMet W g a m.e I gggtgg SiON. *ASHINGTON OC 20566. AND TO THE PAP 9 AveORet T

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eN h Rf DUCTION PRO fE CT (3160410241 088ect OF MANAOt.

MENT AND SUDGE f, ut ASHINGTON DC 20003 w

NAME OF At'PLIGAN1 F ACILIT Y l F ACILITY Docli ET NJesSER A. MEDICAL EXAMINATION CERTIFICATION

• Hl315 TO CF RTIFY THAT THE ABOVE NAMED APPLICANT f *)R AN OPERATDR/ SENIOR OPE RATOR LICENSE HAS SEEN ERAMINED BY A PHYSICIAN PRINT ED N AME tof shyseisnt lST ATE AND LICENSE NUMBER l kXAMINATION DATE SANED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLFANT. THE PHYS.CIAN HA5 DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE RATION AL E RRORS END ANGERING PUBLIC HEALTH AND SAF ETY, i CERTIF Y THAT IN RE ACHING THl$ DETERMINATION. THE GUIDANCE CONT AINED IN ANSI /ANS 3 41983, OR ANSU ANS 16 41977 (N300) W AS FOLLOWED AND THAT DOCUMENTATIONis AVAILABLE FOR REVIEW BY NRC.

ON THE BASISOF THE RECOMMENDATION 0F TifHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO AESTRICTIONS

2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES

3. HEARING A1D BE WORN WHEN PERFORMING (! CENSED DUTIE!

4 RESTRICTED LICENSE OR E XCEPTION. Provide deemis below and attach supportmg medical evidence e r NRC review mem=

6 RESTRICTION CHANGF F ROM PRE VIOUS SUBMITTAL-Provide detads below and attach supporteng medical evttierice for NRC review.

PROPOSED WORDING OF RESTRtCTION (Stock d abowel RE LATIONSHIP OF RESTRICTION TO DISOUALIFvlNG COSIDITION (Snetty mytcare 4cw restreren waticorrect rae assoustr#yeng contsetenf REMARKS FOR RESTRICTION CHANGE (Stock 5 dooset

8. NONMEDICAL CERilflCAllON

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.TIFIES TH AT THE APPLl(, ANT HAS BEEN FOUND TU MEE1 THE SAFEGUAflDS' AND FITNESS FOR DUTY POWE R R E ACTOR $.

m

,JCv:REMENTS OF THIS r ACILITY FOR LICENSED OPE R ATORS.

NON-POWER RE AC'OR$,

' THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS

• REQUIREMENTS OF THis F ACILITY

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FOR LirENSED OPER ATOR$. ANO l HAVE NO KNOWLEDGE OF THE APPLICANT E XCEEDING THE CUTOFF LEVELS FOR ALCOHOL

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OR CONT AOLLED SUBST ANCES AS ESTAE'.lSHED PURSUANT TO 10 CFR 26.

1. _NV e AL55 3T Af tMeNY OH OMis$40N iN TMiS DOCUMENT INCLUOiNu ATT ACHMtN is MAv et 5UGJtGT TO CeylL ANO CFeiMINAL 6ANCIiUN4. l CtH t if f WitH P8NAblY Of ItRJURy THAT THE toFORMA) ON 994 THIS MCUMENT AND ATTACHMENT 513 f %E AND CORRtCT, PAINTED N AME AND SIGNATURE (Sessor Managemerge Repreernrative on Stres TITLE DATE E

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Irt a cordance witn 10 CF R 55.5. Commumcatens. tNi form snail De tut *mtted to tne ilRC as topows; BY MAIL ADDRESSED f O' Regenal Admemstrator. Region i Regenal Admmistrator, Regen il Regions. Admimstrator, Region til U.S, Nuclear Retulatory Commission U.S. Nuclear Regulatory Cornmsmon U S. Nuclear Regulatory Commessen 475 Allendaie Road 101 Marietta Street. Smte 3100 199 Roowveit Road King of Prussia. PA 19406 Atlanta, GA 30323 Cien Enyn. IL 60137 Regenal Adanstrator, Region IV Regional Admimstratos. Region V U.S. Nuclear Regulatory Commission U.S. Nuciest Regulatory Commissen 611 Ryan P1444 Drive. Swr

• 1000 1450 Maria Lane. Suits 110 Arlmgton. TX 760f1 Walnut Creen. CA 94596 PRIVACY ACT ST ATEMENT Pursuant to 6 U.S.C. 552aleH3). enacted mio law by section 3 of the Privacy Act of ROUTINE USES The mformaten may be disc 80 sed to an appropriate Federal. State. or l

1974 (Pubhc Law 91579L the followmq statement is urmshed to mdiv: duals wno loct' agency m tne event ine information meticates a violation or potential violation of law r

supply mformation to the U.S. Nuclear Regulatory Commmion on NRC Form S96 arm m the event the mform.iten moicates a violation or potentias viosaten of law and m This mformation is mamtamed m a system of records desegnated as NRC 16 and the coutw of an admemstratue or audicial proceedmg in additen, th.s mformation may be described at 61 Federal Regrer 33157 ISeptember 18.1986).

transferred to 46 approptre Feders. State, and local agency to ine extent reievant and AUTHORITY: Sections 107 and 1610) of the Atomic Energy Act of 1954. as necesury for an NRC decision aoout you.

amended t42 U.S.C. 2137 and 2201M).

WHETHER DISCLOSURE IS MANDATORY OR v0LUNTARY AND EFFECT ON PRINCIPAL PURPOSElsl: Information ent( ed on tmi form is used to determme INDIVIDUAL OF NOT PROVIDING t.'dFORMATION Disclosure is voluntary, if ene wnerner the pnysical conditen and generai health of the applicant ce such tn t iney reflue5ted m'ormation is not provided. nowever. ine acoucation for a fecHity nuerator's a

will not cause operational errors emurrprmg puc6 c heai.h and w4ty. This mforma - or semer operator s licenw may be demed t'on may be used by the NRC staff to determine if trie individual meets tne require-SYSTEM MANAGERISI AND ADDRESS Chief. Operator Licensing Brancn. Office of

melts of 10 CF R 55 to w-e an exammation or to be issued an operamr's hcense Nacle.r Reactor Regulaten. Uf, Nuclear Requ story Can miwon. Wasmngton. DC 20555 e

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1 INCU350RE 3 StHERY OF QWMS '!O HNC FORT 396 N iemi Examination Certification Added block "Hestriction Qanse Frca Prwious Suhaittal" plus Rasarts i

martion.

Non-Medical Certification Changed naa h certifiestion sta*mment to: Peuer Beestore-This certifies dat the asolicent has been found to meet the safeguards' and fitness for chrty requiremer.ts of this this facility for llammmed operators.

Nonpomer-This certifies that One i

asylicent has been found to meet the enfssuants' requirements of this i

facility for licensed eserstore and I have no kneeladge of the applicent esosoding the autoff levels for alcohol or controlled substances as established pursuant to 10 Crit 26.

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1 DOASURE 4 Sttt%RY OF ClutMS M W fotM 396 Item 4.d Added clarifying statament to indiasta this is to be checked only if application is to amend license to j

add additional unit (s),

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Item 4.f Added "(Categorr)" to operating.

Adde.d " Medical".

Item 4.s Added a new item "Date Passed Generic Fundamentale Exmaination Section".

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Itam 12.3 Changed wording to "CertMind Startaap Progren Ocupleted" for clarification.

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Item 12.5 Chansed wording to " Extra Person on Shift In Centrol Room (13-week minimum)" for clarification.

l Item 12.5a Added a new item " Time on Shift Above 20E Power (6-week i

minima)".

i Item 14.a Added the words "That Is Bened Upon A Systems Approach to Tr=4a4a=" for clarification.

Itan 15 Added "Date and Beault of Most Rosent HRC Administered Req W ification ih==4 nation".

Item 19.a Added the wording "I Aarther certify that I have notified my ournat employer of t (1) all pewfous employers (2) any inscence where I have been tested by a Health and Human Services (HIIB) Certified Ens footing Laboratory or a Licensee's testing facility for alochol or a controlled substanoe, and the test resulta 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 substance described in 10 CFR Part 26: and (4) any reemans for removal or twoostion 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 nome of T sinins Coordinator and Senior Manneement Representative On Site.

FOR HIIC USE thder waiver category added " Medical".

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