ML20006D904

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

ML20006D904
Person / Time
Site:	Armed Forces Radiobiology Research Institute
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Irving G ARMED FORCES RADIOBIOLOGICAL RESEARCH INSTITUTE
References
NUDOCS 9002150233
Download: ML20006D904 (8)

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.IMI 5 1990 Docket No:- 50-170 t

-Defense Nuclear Agency Armed Forces: Radiobiology Research Institute ATTN: : Colonel George Irving, III.,MC, USAF Director Bethesda, Maryland 20814-5145 s

' 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, p

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

Changes to NRC Form-398 are detailed in Enclosure 4.

i A11= 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, ll.S. Nuclear Regulatory Commission; by telephone

-(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 have'any questions regarding these. forms, please. contact Richard J.

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

Sincerely, i

L Driginni Signed Ey:

6:

Robert M. Gallo, Chief Operations Branch Division of Reactor Safety I

Enclosures:

As stated f

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OFFICIAL RECORD COPY 396 & 398 FORMS - 0041.0.0 12/14/89 l9002150233.900105 ij PDR.ADOCK 05000170 y

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Defense. Nuclear Agencyf 2'

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ll M. ~ L. Moore, Reactor Facility Director.

Dr.. William Vernetson, Director of Nuclear Facilities, University of Florida Public Document Room (PDR) in -

Local Public Document Room (LPDR)

Nuclear Safety'Information Center (NSIC)

. State of Maryland (2) bec w/o enc 1:

A Region I Docket Room (withjconcurrences)

ManagementAssistant,DRMA(w/oenc1)

D.-Haverkamp, DRP J. Linville, DRP-T.- Kenny, SRI - Limerick'

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0FFICIAL RECORD COPY 396 & 398 FORMS - 0042.0.0

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INSTZUCTIONS FOR COMPLETING NM FORM 300 PE TONAL CUALIFICATf 0N STATE"ENT-LICENBEE 1

' TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED 4

TYPE CF APPLICATION 2.s NEW "X" lF YOU ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE

)

INSTRUCTIONS BELOW. THIC IS TO INCLUDE ALL EDUCATION, TRAIMNG AND EXPERIENCE THAT YOU HAVE.

RECElVED UP TO THE DATE OF THis APPLICATJON. NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED lF PREVIOUS NEW APPLICATION WAS WITHORAWN. PLEASE WRITE " WITHDREW" NEXT TO "N EW,"

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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 RECEIVED SINCE YOUR LAST APPLICATION. NOTE: SEE ITEM f4 - THERE IS AN 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 YOUR LICENSE TO A SRO.

2.d MULT1. UNIT "X" (F YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

l 2.e REAPPLICATION

• • X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

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

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

THIS l$ NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR TME 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 1.1DB2,WHICH LED TO THE ISSUANCE OF A LICENSE,1HIS 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 Tile HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH' AS NUCLEAR POWER 3CHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, OlESEL MECHANIC SCHOOL, ETC, i

INDICATE THE NUMBER OF MONTHS IN EACH PROGitAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED. IF AD TlONAL 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 40U NEED FURTHER CLARIFICATION, INCLUDE DOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMpER OF WEEKS SPENT 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 UNDER EXPERIENCE (ITEM 13).

ALL REQUALIFICATION TRAINING TIME IS TO I;E ACCOUNTED FOR IN THE REQUALIFICATION 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 POSITION 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 SHOULO TH NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

14 FACILITY O.w..RATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROG PE mw ~

... 7 3 -. -

• m NRC APPROVED SIMULATION FACILO d ww m e nc vrtneu vH I HMNING PHO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14.a 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 NUMBE OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY T 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 REQUAllFICATION E 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 TH CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TlON.

.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 MANAGEMENT REPRESENTATIVE ON SITE.

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

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06d.end 66.67 ESTIMATED BURCEN PER RESPONSE TO COMPLY WITH THl3 INFORM ATION COLLECTION REQUEST: 2D HR$.

FORWARD COMMENTS REGARDINO BURDEN E STIM AT E

. PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE iNFORMATiON AND RECORDS manAGEutNT

$ RANCH (P 630L U S. NUCLE AR REOULATORY COMMIS-SiON. W ASHINGTON. DC 20666 AND TO THE PAPERWORK REDUCTION PROJECT (31600000). OFFICE OF MANAOE-1 TO REMAIN VALID,THis FORM MUST NOT BE ALTERED MENT AND SUDGET, W AsHINOTON. DC 20603.

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4. TYPE OF APPLICATION (OscA app / cable boass) 1 HOT l

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13. STAFF / SHIFT ENGINEER (tscensedi 7-OTHER tspees&l

14. AUX./EOUIP. OPERATOR (Non/renseds

15. PLANT STAFF 16 OTHER Ispeci&1 NRC FORM 385110493 -

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4-b, DATE AND RESULT OF MOST DA' "E8US' teDUR$ OPE RATED F ACILITY:.

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16. EXPERIENCE OETAILS

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18. NRC PORM 306 CERTIFICATION OF MEDICAL E XAMINATION SY FACILITY LICENSEE,68 ATTACHED ANY F ALSE ST ATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUILIECT TO CivtL AND CRIMINA[$ANCTIONS.

tee.. I manity unser poneny of periury that the informeilen in ihm document and attahmente is true and correct. I turther certify inst I have notified my cunent empiover of: 41) en pnevious enoievers,

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. (2) eny messnes unene i how Deen tested by a Hestth ensi Hurnen Services lHH8) Certafeed Drue Tessine Lenoretory or a Licensee's testing tec61 sty ter alcot.se or a controleert auf1eence, and the test D

susums essessed the outett mwn es.emenhed pursuant to to CFR Port 26;(3) any 6nsience where i how been arrested for the este, use er possesen of a coetteiled substance deserted in to CFR Port 26; '

and (4) any reasons for remesse or rowestton of wnestortal access et e nucieertlecil6ty, t eine authortse the NRC to outwnst the resuets of ensnunstens to t*y ernolovere for use en preparing reireenmg pseemme, a nemmeery 840 NATURE-APPLICANT DATE CHECM APPLICABLE SOX l h I sortie that the enove named trunwedusi hee succoufutiv somputed the factiny luasses requiremeais to he beened as en Operatort$sator Operator pursuant to Tale to, Code of f adored Regusettone.

v Pen es:and that the indhr6duni has a need eor en Operator /senter Operetor twenn to perform hu/her eeuened dutos and thei the asseuse.me en mese evenehm for saammeien. I esso certify unaar

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senesty of portury that the intermeten in thee document and ettechments is true eres correct.

- e, RENEWAL ONLY - I certify that the ecow named indereduet meets the sporowed requeilfication progreen (wirA emceptene noced Jie trem f h as required by section 60.6416 0 of to CFM 60. sad that he/she has discherged Ns/fier hcorised retoonsibNnare competently and asfety. I eieo certtry under penest, et penury shot the informetion la this document and attacaments.

Is true end correct.

TRAIN;NG COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAMk i

lDATE lDATE l

StGNATURE SiONATURE FOR NRC USE WAIVER (Check or compiere / rems, as applicablel l MEET 8 REQUIREMENTS l l DOES NOT MEET REQUIREMENTS Msadeln 6ed OnANTeDev DeNie D e v CATEGORY-HhanouAnfans mEotoN Ha AcovARTr ns n a cioN WRITTEN OPERATING ELIGIBILITY

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NAME OF APPLICANT l F ACILITY DOCKET Nuna0ER F ACILITY A. MEDICAL EXAMINATION CERTIFICATION THl3 IS TO CE R TIF Y THAT THE ADOVE NAMED APPLICANT FOR AN OPE R ATOR' SENIOR OPE RATOR LICENSE HAS BEEN E AAMINED SY A PHYSICIAN PRIN T E D N AM3 Iof onysrc,anj lST ATE AND LICENSE NUMBER l E XAMINATION D ATE B ASED ON THE RESULTS OF THE EXAMINATION INC' UDING INFORMATION F URNISHED BY THE APPLICANT THE PHYSICIAN MAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONOlTION AND GENE R AL Hi ALTH ARE NOT SUCH THAT 17 MIGHT CAUSE OPER ATION AL E RROR$ ENDANGERING PUBLIC HE ALTH AND SAF F.TY. I CERTIFY THAT IN RE ACHING THIS DETE RMIN ATION. THE GUIDANCE CONT AINED IN ANSUANS 3 41983.OR ANSI /ANS 16 419771N3H01 WAS FOLLOWED AND THAT DOCUMENT ATION l$ AVAILABLE FOR REVIEW BY NRC, ON THE BASIS OF THE RECOMMENDATION OF THRHYSICIAN. I RECOMMENO THAT THE APPLICANT'S OPER ATOR LICEN3E RE CONDITIONED AS FOLLOWS.

1, NO RESTRICTIONS

2. CORRECTIVE LENSES SE WORN WHEN PERFORMING LICENSED OUTIES 3, HE ARING A10 BE WORN WHEN PE RFORMING LICENSED DUTIES 4 RESTRICTED LICENSE OR E XCEPTION Provide de*N heia* and sitsch supportmq medical evidence for NRC review t REST RfCTION CHANGE F ROM PRE VIOUS SUBMITT AL.Pmvide eletails below amt attach suponrtae'1 meilical evielence for NRC review PROPOSED WORDING OF RESTRICTION f8hre d ateves M LATIONSHIP OF R ESTRICTION TO DISOUALIF YING CONDITION (pneny,ms, care now restncien win convet the descueseryme cona,rens REMARKS FOR RESTRICTION CHANGE IStoca 5 arsovel

8. NONMEDICAL CERiltICAflON POWE R RE ACTORS THIS CER TIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEE T THE SAF EQUARDS* AND FITNESS FOR DUTY REQUIREMENTS ?F THIS F ACILITY FOR LICENSED OPERATORS NON POWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS flEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THis FACILITY FOR LICENSED OPER ATORS. AND 1 HAVE NO KNOWLEDGE OF THE APPL' CANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS EST A8LISHED PURSUANT TO to CF R 16 LNV # AL5h ST A rtMtNr un OMi5540N IN f HiS DOCUMtN T #NCLUDiNu Af f ACHMLNT5 May SL SUWJtCt TO Civit ANO LNtM4NAL SANCliuNan 8 C4 H lie r uNut H t N Ab f r ut PERJuMY THAT THS INFORMAfiON 88. THI$ DOCUMENT ANO AT'T ACHMENTS 15 f auf AND CommeCf.

PRINTED NAME AND SIGN ATURE ($ener Marnegement Neorewntarne on Sures iliLE DATE in accorcance with 10 CF R 55.5. Commumcations inn form shall be sut>mitted to the NHC as tonown: 8 Y MAIL ADDRt SSED TO.

Reponal Admemstrator. Repon i Regional Adminstrator, Region H Regional Admi:totrator. Repon H6 U.S. Nuclear Regulatory Comm.suon U S Nuclear Requierary Commisuon U S Nuclear Requicory Comminion 475 Allemlase Road 101 Marietta Street. Suite 3100 199 Rooseveit Roan King of Pnaus. PA 19406 Atlanta GA 30323 Glen Ellyn, IL tiOl37 Regional Admmiserator. Region iv Ratonas Admentrator. Region V U.5. Nuciear Relutatory Cornmaueon U S Nuclear Regulatory Cornmission 611 Ryan Plata Drive Suite 1000 14'>0 Maru Lane. Smte 210 Achnston. TX 76011 Wainut Creeni. CA 94506 PRiv ACY AC T ST AT EMtN r Pursuant to 5 U.S C 5524teH31. enactal into law ov wetion 3 of the Privav Act of ROUTINE USES The m'ormatma may ne delows to aa apenmoete Fmiere. Stee. or 1974 (Puhht Law 9}579L the followmq itatement is urnisheit to imlividuatg who local egency m the event the mformaten malicates a viusation or iotential violation of law s

supply information to the U S. Nuclear Requiator) Comminion on NRC Form 3"*

and m the event the mtormaten m6scates a velaten or oorentes vmiaten of law arul m This information is maintamed m a system of escords deseginatal as NRC 16 and the courw of an admimstrahve or nudicial proceeding in al+ter). te.s inroemation may be described at 51 Federal Regater 33151 (Seotemt er 18.19861 traniterred to an sopropriate Federai. State, ami loca agency to tee estent itiovani and AUTHORITY Sections 107 and 16101 of the Atomic Enenry Act of 1954, as noteswy for an NRC decision atmut you amemsel l47 U S C 2137 and 22011:0 WHE THER OtSCLOSURE IS MANDATORY OR v0LUNTARY AND ESUCT ON PRINCIPAL PURPOSEISL Information enteres on thes form a umt to cetermme IN0lV10 VAL OF NOT PROvlDING INFORMAf TON Dactowse a wuntary if the whether the pnysical combien erus genery hesith of the aposicant are sucn that they requested mtormation 4 not provated nowever the appaicaten for a facuitv operator's will not cause comratonat errors endangenne puniec nearth and safety The mturma or sener operato' I incense may ne osmal leon enay De uses by tne NRC ttaff to determme it ene muevidual meiets the require SYSTEM MANAGER (SI AND ADDRESS Chief. Operame tscenging Br4nch Omce of

. ments of 10 CF R 55 to tane en esam naten or to be nsued an operator s ocense Nucieer Reactor Pegut.stion U S Nuctear Requiatory Commewon. wnhmgron. DC 20555 Nec some vut ma9i

.i DCL46015 3 S39%RY OF QUMES 10 Nic PolM 396

=

Medical Examination Certification Added bM " Restriction Qanse Fron Prwious Submittal" plus Raamrts section.

Non-Medical Certification Omnsed nondi=1 certifiestion statament to: Power Beactors-This certifies that the asqplicant has been found to meet the safeguards' and fitness for &rty requirements of this this facility for licensed operators.

Nonpower-this certifies that the asqplicant has been found to amet the safegummis' requiremama of this facility for licensed opeastors and I have no kriemledge of the applicant y

emanMrig the carteff levels for alochol 5

or controlla.i substerow as establimbed

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9 Dt24lSURE 4 StAttARY OF OttWEB 10180 F0lM 398 l

Item 4.d Added clarifying statement to indiasta this is to be checked caly if application is to===wl lionnee to add additional tait (s).

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

Added "Hadinal".

Itan 4.s Added a new item "Date Panned Generic Furidan=ntals Examination Section".

i Item 12.3 Qiansed wording to " Certified Startup Program Completed" for clarification.

Item 12.5 Chansed wording to " Extra 1%reen Qa Shift In Control Rom (13-week minime)" for clarification.

Item 12.5a

- Added a new item " Time On Shift Ahove 205 Power (6-ween minima)".

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~ Adde 6 the worda "hv Is Manet' Usen A System Aw.ves to '"taintos" Dr claritiast%cn.

l Ivan 15 AedN "Ihte arr.: Result of Nort Aeoant NRC Administ.ored i

Bee =14*icatica lhtion".

It o 19.a Added the teordint "I.*.trthar certify that I have notified tff currwh wmloyer of t G) all.prwsous eeloyers; (2) av I

instanes. @Are I have been tested by a Health and Human 1

Services (HRB) Certifis4 Dnar Testing Laboratory or a I

Licensee's testing facility for alnahol or a controlled substanos, and the test results esconded the cutoff levels l

established sursuant 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 twvocation of unescorted i

acosas at a nuclear facility".

Item 19.b and Item 15.c Moved 19.b and 19.c tesother. Applicable bax aust now be checked. Also added block for typed nees of Training Coordinator and Senior Menessment Representative On Site.

ICR NRC USE Onder waiver cetesorr added " Medical".

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