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Request for OMB Review & Supporting Statement Re 10CFR55.60, Certificate of Medical History.Estimated Respondent Burden Is 750-h
	ML20054K089
Person / Time
Issue date:	05/06/1982
From:	Norry P, Scott R; NRC OFFICE OF ADMINISTRATION (ADM)
To:	;
Shared Package
ML20054K088	List: ML20054K087; ML20054K089;
References
	OMB-3150-0024, OMB-3150-24, NUDOCS 8207010051
	Download: ML20054K089 (6)
	v • d • e

REQUEST FOR OMB REVIEW (Und2r ths Paperriork R: duction Act and Exscutiva Order 12291)

Imp 2rtant - Read instructions (SF-83A) before completing this

'Offsce of information and Regulatory Aff airs form. Submst the requirednumber of copies of SF 83.together Offsce of Management and Budget with the material for which review is requested to:

Wa shington. D C. 20503

1. D*pa'tment/ Agency and B Aeau/ Office originating request 3 Name(s) and telephone number (s) of person (s) who can best answer questions regarding request U.S. Nuclear Regulatory Commission Don Becklam (301) 492-7843 2.6-dsgst Agency) Bureau number (Isrstpart of 11-drgot Treasury 4.3 digit functsonalcode tisstpartof 11 digit Treasury Account Account No )

No.)

_3. _.1 0_ -2

__0 0_

_ 2

_7_ 4_.

b. Tills of information Collection or Rulemaking C. Is this a rulemaking subentssion under Sectson 3504 th) of P.L. 96 5117 (Check one) 10 CFR 55.60, Certificate of Medical History inNo tsection 3so7 suom ssion) 2 0 Yes. NPRM. Expected date of publ cat +on:

i

b. A Is any ontormetton collectron (reporting or recordkeeping) 3 0 Yes.tsnal rufe. Expec4d Cate of puoi,catiost;,

involved? (Check one)

Effectate date:

IdYes and prcoosat is attached for review D. At what phase of rulemaking is this submission made?

ck ond 2 O yes tut orcoosa'is not attached - skip to question D 3 O No - skip to cuestion D 1 MNot applicable B Are the respondents primanly educationalagencies or 2 0 Manor rufe at NPRM stsee snstotutions oris the purpose related to Federaleducation 3 0 Major Final rule for whec41 no NPRM was published programs ?

e O Major Final rule.af ter publication of NPRM O yes C No 5 O Nonmajor rule,at NPRM stage 6 O Nonmajor rule. at Final stago COMPLETE SHADED PORTION IF INFORM ATION COLLECTION PMOPOS AL IS ATTACHED

, 7. Current (or former) OM B Number 8 Requested

12. Agency report form number (s) 3150-0024 Expration Date NRC Form 396 Expiration Date

13. Are respondents only Federal agencies?

May 31 1982 May 31.1985 O Yes

@(No

9. Is prooosed information cnllection listed in

14. Type of request (ChecA one) the erformation collection budget?

[X Yes O No 1 O preliminary plan

10. Will tms proposed intormation co'lection 2 O new (notpreviously approved or expired more than 6 months cause the agency to exceed its information ago) collection budget allowance? (if yes, attach O Yes Kl No 3 0 revision at:.cndment request from agency head.)

e C extension ladiustment to burden only)

11. Number of report forms submitted for approval 5gentension (no change)

One (11 60'*"*"'"'"''P"'**d"'"6"*"'"'

15.

16. Classification of Change in Burden (explain in supporting statement) a Approemete 5 re ct N/A No of Responses No of Reporting Houts Cost to the Public N/A

a. in inventory l

b sin of iemo

s c Est.=sted nur ber et

b. As proposed i

respoaceats or

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C c' d " " P' D' 9"'

3,000

c. Dif f erence (b-a) us, e, ntn Explanation of difference (indicate as many as apply) d nencessana a

ratpondenttsee 25)

}

Adjustments e Totzt saaueiresonase'

+

<,te, r3e, tsoi d Correction-error S

3'000

e. Correction-reestimate i i

iS t teen ssode,e, age nu, ee< o' w' 4

I Changein use g

pr' '" ""

.25 Program changes g Est.metad ** et houts ov e nnwei bueoea la g increase

+

+S Dscal veer l

totsm see 1 tsr1 75_0 h Decrease

_g 8207010051 820505 i

l PDR ORO EUSO!1B standard Form e3 tRev. 3.s i PDR For Use Beginning 4/1/81 t

17. Abstract-Nssds and Us:s (50 words orloss)

Provides basic data for agency review of the tnedical history of applicants /rcn::wal requests for operator and senior operator licenses.

18 Petated report f orm(s) (give OMB number (s). lRCNfs),

~20. Catalog of Federal Domestic Assistance Program Number ontstnal a gency report form number (s) or syrnbol(s))

21. Smatt business or organization O Yes O(No 19 Type of affected public (Check as many as appfy)

I22. Type of activity of affected public-indicate 3-digit Standard

* *

U U '* '

1 p(indsvoduals or households

~

10, check O Multiple or O All 2 O state orlocalgovernments 3 0 farms 4 0 businesses or otherinstitutions (except farms)

_ Q. _.8.

1 23 Brust descrsption of affected pubfic le g."retailgrocery stores."" State education agencies,Wouseholdsin 50 largest SMSAs")

Operator and senior operator license applicants 24 Purpose (Check as many as apply Itmore than one. Indicate 26 Collection method (Check as many as apply) predomsnant by an asterssk) 1 % mail self-administered 1 O application for benefits 20 other self administered 2 O program evaluation 30 telephoneinterview 3 O generat purpose statistics 4 O personalinterview 4 D regulatory or compliance 50 recordkeeping requirement:

5 O program planning or management Required retention period; years 6 0 research 6 0 other-describe:

25 Frequency cf Use

27. Collection agent (Check one) 1 O Ncntecurring 1 q requesting Department / Agency Recurring (check as many as apply) 2 O other Federal Department / Agency 2)(2 on occasion 6O semiannuelly 3 0 private contractor 3 0 weekly 70 annually 4 0 recordkeeping recuirement 4 0 monthly 80 ciennially 5 O other-describe:

5 O quarter:y 90 otner-describe:

28 Authority for agency for information collection or

. 30. Do you promise confidentiality?

rutemaking-ind.cate statute. regulation, judicial decree, (If yes, explain basts torpledge etc.

in supporting statement )

E Yes O No Atoraic Energy Act of 1954

31. witi the orcposed information ceitection create a new er become part of an existing Privacy Act system of records, 29 Respondent's cbugation to repiy (Check as manyas apply)

(If yes, attach FederalRegister notice orproposed draft ot*

1 A.rotuntary nof'Ce I O Yes D No 2 O required to obtain or retain benefit

32. Cost to Federal Government of 3 0 mandatory-cite statute not CFR fattach copy of nformation collection or rulemaking S_15.600 statutory autnority)

COMPLETE ITEMS 33 THRU 35 ONLY IF RULEMAKING SUBMISSION 33 Ocmpliance costs to the public

,34 is tr.ere a regulatory impact

35. ls there a statutory orludicial analysis attached 7 deadline af fecting issuance?

I 5

l O Yes O No O Yes$ Enter date l

O No CERTIFIC ATION BY AUTHORIZED OFFICf ALS SUBMITTING REQUEST-We certify that the information collection or rulemaking submitted fer rev.e. is necessary for the proper performance of trte agency's f unctions. that the proposat represents the minimum public burden and Federal cost cons s'ent mth need a9d is consistent *:th appocabre OMB and agency policy d:rectives Signature and title of.

sepamms py,ic, orr.c.a. eon act v

caTE sueu TT%s orriciat cars b

1 SUPPORTING STATEMENT FOR NRC FORM 396

" Certificate of Medical History",10 CFR 55.60 Justification Required medical information shall be provided to NRC on NRC Form 396, 10 CFR 55.60 " Certificate of Medical History," which is required of all applicants for operator and senior operator licenses (10 CFR 55.10(a)(7)),

and for renewal of these licenses (10 CFR 55.33(a)(6)). The completed form is utilized by the NRC Consultant Examining Physician to determine whether the

~

physical condition and the general health of the applicant are not such as might cause operational errors endangering public health and safety (10 CFR 55.11(a)).

The data provided by the applicants is reviewed by the clerical staff of the Operator Licensing Branch to determine whether all appropriate items have been completed and then are forwarded to the NRC Consultant Examining Physician for review and final approval.

The NRC Form 396 is again reviewed by clerical staff to ensure completeness.

Tabulation and publication plans Inforration will not be published.

Time Schedule for data collection Certificate is submitted at the time of application for an operator's or senior operator's license.

Certificate is submitted at the time of renewal application for an operator's or senior operator's license.

Consultations outside the agency There have been no formal consultations outside the NRC regarding this form.

Estimation of compliance burden Approximately 3,000 applicants (new and renewal) are expected to complete the form annually. The burden per applicant is estimated to be approximately 15 minutes for the applicant (page 1) for a total burden of 750 hours0.00868 days 0.208 hours 0.00124 weeks 2.85375e-4 months .

Estimate of cost to the Federal Government Estimate of annual cost to the Federal Government includes:

. NRCConsultantExamin[ngPhysicia' 45 days X $160 = $7,200.00.

A.

n B.

Initial clerical review, 3,000 X 2 minutes = 100 hours0.00116 days 0.0278 hours 1.653439e-4 weeks 3.805e-5 months at $14/ hour

= $1,400.

C.

Final review, 3,000 X 10 minutes = 500 hours0.00579 days 0.139 hours 8.267196e-4 weeks 1.9025e-4 months at $14/ hour = $7,000.

Therefore the total cost is approximately $15,600.

Provisions for confidentiality of information The information submitted to NRC by applicants as a result of the certificate requirement is not available for public inspection.

E 6

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e NRC FORid 2n U.S. NUCLEAR REGULATORY COMMISSION oc opre=s ey Onda CERTIFICATE OF MEDICAL HISTORY For Fa:!!Pty Operator's or Senior Coerator's Ucense em1T54UCivCN 1 A spacane mwat como.ete aJa nome on page 1. 7,T,+4e er pnet m ina. Pnysac.an anwat compiois all rema on page 2.

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[ FIRST NaWE jWiDouNAME

2. DATEOF taRTet 1 0+DM E ADOR E SS

8. SEX MAYE YOU DER M AD OR DO YOU NOW MAvE ANY OF THE FOLLOWINQt GtvE DETAJLS OF ANY CONDmON ANSWERED AFF1RW ATTVELY UNDERI DESCRIPTION YE.S NO DESCRIPTION Ms NO S. Snowa4** ' ear

18. Bone, joint, or omer deformary

4. Freqwent or **Mrs heecacnee 1T. Pamfulor"tric4"shov6 der T. Diz22aese or tamt'ne scene 1a. Pasarulor"tnca"ertoe L tre trowa$e it. Perstysse q,

S. taadetoe

20. Epsooeyorsatturne

13. Tvt+rtwoe.s

21. Copresaton or esceaaNe worry

11. Chronst snortneee of tweem

22. Lose of enemory or amnese

12. Pam er eresawre m teest or Deart anact"

23. Nervows concit*on whicri could Impair 11 M.On tNood pressure jwegmerit er ror.abittty '

14. Low tecod prere 34, D,vg, na,onc,wi e, e,ces.se.nnain, it Peptic ear 2s. Do you normany war eyestasees?

COWeUTE EACH CF TME FOLLOWtNG.GNE CETAILS OF EVERY AFFIRW ATIVE AN$WER UNDER ITEM 38.

QUESTION YES NO

25. Ars yow taaseg any routmo medcanon?

27. Mae yove wort ever been ilmned or reatncted for medic.al reasons?

25. ** ace yow ever t+en denied or rated up for tife 6nsursace for emed cal reasons?

29. Me M yow egr t+en under observooon or receeved care or treatmeest for any mentaJ or nervowa conditions as a pas.ent an a hospital. sannortum, clanec or other facetry. or from a p e.an, cJN t'syehososiet, etc.?

3L have yow ever teen re ecW for or d.acnarged from employment or mitMary service for pnysical mental or nervows diaorcer?

31. Ham ym ever rece4ved,Is tnere pendang have you apphed for. or do you antead to appsy for pensaon or coraipensanon for esesong disability?

22. kan you one eenoweiy considered commerung swecide?

33. Man you ever t+ea coavicted of any veonation of FederaJ taw. State law. county or municipal law. requianone or ordmance? Do not incauce anything that happened be8cre your team tw1nda y. Do not inctwo e vio.anons for which a fine of 125 or less was ernposed.

34. Have row ever nad any may timosa or injury otner ma'i tnose aiready noted?

15. how maa, Joes have you P6ad in the last 3 years?

38. vost le tse son;s of time M your oresent emosoyment?

37. CNE A ga EP STATEWENT OF YOURPRESENT HEALTHIN YOUR OWN WORDS

34. O'T A3LS Or AN Y ITEW. 5 THROUOM 34. ANSWERED IN THE AFFIRW AftVE.(in additJon, if yourmedicallusfory mer des a ny marier relafsnp ro pnyecal, mentat. armervows coruseorie, v

pense deacM%e tne cond.Uon and set forth your esp.a nstron of any tfits malter wowed not a**ect you9 a.Wi!!y to functson as & faculty opereror. Use a0dttoonalsneet f amore spegg 6g ased.

ed)

Jd. e CLR146 Y IN AI TML FCHEGOWG sNFOHuallO's SUPPLIED BY WE is T AUF 10 TME BEST CF Wf RNQwLEDGE. AND AUTHOA.2E IME U.S. NUCLEAR PEGULATORY COMutS510M l

TQ USE ANY OF THE INFOaW ATiON IN TMt3 CERTIFICATE IN TME EXERCISE OF ITS AUTHOR.TY OVER THE UCEhslNG OF OPERATOR $ (SJgn powrnarne M int as Jrappears omI yourew: anon foroce-ads eennaropererore ncensel

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PRYACY ACT STATEWENT Pwessant to S U 5 C. S$2sts v31. enacted late law by section 3 of me Prwecy Act of 1974 (Nbibc ROUTIN E U'SE S. The infore s tion ma y be diactose a to an acprognate FederaA Soste, se toc.al (rw $W11. ene tonowmqstsiement is tumioned to taciviewals w*e swep*y mtormaten to the agency m the event tne an+ormation end cates a vio'ation or octeemas violation or sew anic en the i

U.S. 8 wcwe=Roovemry Lemmisaaon on NRC Form 36. The eMormanon 6s memtamed m e event the anformanon endcates a vio: anon or potentes v50.ation at la w and in the course of an es.

i evetem of recort a dea 4nated as NRC.16 and descriDed at 40 Federal Register 4533hsetocer 1 mmestratrve or ludc.al proc eedmg. m a sertion. tnis informat.on unay De transferred to are e p-l 16T5L proonste F ederai. Sta te, and locaa atency to the estent re'svant and nece neary nor an postC doch AUTHOZrTY. Sectione 107 and to til) of tne Atomic Energy Act of 1954, as amended (42 U.S.C.

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2137 cnd 2Mtm..

wwETHER Dr$CLOSUPE t$ W ANDATORY OR YOLUNTARY AK! iFTECT ON porveDUAL OF PW:ies.L PUe POSEi$) Informetion ente ed on mte form is veed to deae tabe w*etner the NOT PROW 3NG IMORW AMNDC28um is volunWy. H me reqwested inNmemn se not p6

,a,on.u, vers e,ca,,en,onv.ai nee'.in,n aed e,o..y. Th.s iMo, mar en m.,,as not cawee opere-y,*jd'*'"me appucapon fut a tapTy opvators or senior opcstar's nicense may be nys l corction and c of the ap ncaat are swe's tant me, w e

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.e no ewe.d ymeNRC eran te estewne of tne ma'veveJ meeta too reqwerements of 10 CFR SS ta inne an examinanon or SYSTEW MAN AGE R:$) AND ADDRESS. CMef. Operator Oceaslag Branch. Omco eH6ucaser i to ti.e.seved ee ooveeore incense.

Reector Regwete% U.S. Nwcioar pegwia tory Comm.se.ca. Weefuncto% DC 2tma

CEDICAL EXAMIN ATl!N

' f(W2E A 0;cTNu lT IS ES3ENTIAL TH AT EACH ITEM ON THIS TAGE B3 CCMPLETED. Si;n this Cert:f44te cte rniit to:

IF:t a rea ctor tperstziloc:nse)

(Fora re reactoroperstorticense)

Otrector O*fde cf Nw:. ear Reactor Re;ufation Director, DMs.cn of FuelCycle and Matertaj Safety U.S. Nuctoa; R ogalstory Commission U.S. Nuc!sar Re:wlatory Commisalort W:shington. DC 2 CMS Washingtort DC20555 m,n.cumi s,w.asv ae ssocmaro oe tre wtoca meroav raou rno=t oe ntaant. usa noor mu s tri r uoat seAca s atsota.

-o hsTm CToess S=e seemos of annerwe, howerge vaser nem 23 messe.

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puGMT tY1 LarTIT3 angTHQO utaD L DestawT vmAk aCapTv useCDantCTTD 21 3Di

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C.sfamf vs.A6 Acur?YCDapfCTED 3e#

ml E kl.AA v6WA acurfv utoCDattCTED' 301 30#

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htA2 W644 &CRJfrT ComarMg fees eeneed erwy aespessee ewisee me mouneer eersy 308 2Dr ll l

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1 4 W so. ETsa.GDetML tL mtasise.g aswi t.AA LaFT tAA wgTW W&as is tam o=wie it. EAAn. caatmAL it.twr is. vascuLAmsr:Tsu satosc atsutu oe run romeoo o ExAumArom Yes i.e.

20. waa thee a y p*,sowe. motor so.rer, ri go of motion. or eer'erity cisorcer wmen wowid not snow ryesy acceas to. and safe esecuthmer assigned dutieet

21. was two a*y conemon hatat or proctace wae m'gmt resutt la sodoom or vaespected tacaseenstion, 4

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22. DETAJLS AND EVALUATION OF ANY (TEW 1 THROUON 22 A80VE PEPORTED ABNomW AL AND SUMWARY EVALUATION OF CVER-ALLCONDmOM Iwestas ea: any et t% information in tmis esawnst.on may t>e wsed by the U.S. Nucmar megatory comm. won 6a re e:ercae of ste s.m o e y e ric ne.ag of operweers.

SGN ATURE CF PHYSC.AN I

l DATE

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i TWED oa PminiTID N AW E CF E.XAMINING PHYSCAN l PNY$CAN'S A.DontEs l STATIIN WHCH UCE's&ED CE MIN DEP;7 is R EculR ED TH AT EVERY ITEM ON THIS PAG E BE COMPLETED EXCEPT THOSE M ARKED WITH AN

WHEN NOT APPUCASLL SEND THIS CERTIFIOATE TO THE PROPER ADDRES.S USTED A50VL N!aC FORM 3G4 cres o e o si 4 i s.

ML20054K089

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