Text

Notice of Pending NRC Action to Submit Info Collection Request to OMB & Solicitation of Public Comment Re NRC Form 398, Personal Qualification Statement - Licensee
	ML20141G717
Person / Time
Issue date:	05/21/1997
From:	Levin A; NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
To:	;
References
	OMB-3150-0090, OMB-3150-90, NUDOCS 9705220469
	Download: ML20141G717 (13)
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[7590-01-P]

- U. S. NUCLEAR REGULATORY COMMISSION Agency Information Collection Activities: Proposed Collection; Comment Request

' AGENCY: U. S. Nuclear Regulatory Commission (NRC)

ACTION: Notice of pending NRC action to submit an information collection request to 0MB and solicitation of public comment. ,

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SUMMARY

The NRC is preparing a submittal to OMB for review of continued approval c.f information collections under the provisions of the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35).

Information pertaining to the requirement to be submitted:

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1. The title of the information collection: NRC Form 398, l

" Personal Qualification Statement - Licensee"

2. Current OM8 approval number: 3150-0090 p 4/[

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>c cff4 How often the collection is required: On occasion and every l

six years (at renewal).

Who is required or asked to report: Individuals requiring a dr [(l' 4.

i pg e licensee to operate the controls at a nuclear reactor.

97052a'0469 970521 PDR. ORG EUS 9

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J The number of annual respondents: 1660 annually

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6. The number of hours needed annually to complete the-

' requirement or request: 1730; approximately 1.04 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months per response. f

- 7. Abstract: NRC Form 398 requests detailed information that ,

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' should be submitted by a licensing candidate when applying s

for a new or renewal license to operate the controls at a ;

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nuclear reactor facility. This information, once collected, !

would be used for licensing actions and for generating .l I' reports on the Operator Licensing Program.

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Submit, by (insert date 60 days after publication in the Federal Reaister),

comments that address the following questions:

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1. Is the proposed collection of information necessary for the i

NRC to properly perform its functions? Does the information have practical utility? ;

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2. Is the burden estimate accurate? ,

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3. Is' there a way.'to enhance the quality, utility, and clarity j

.of the information to be collected?

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4. llow can the burden of the information collection be minimized, including the use of automated collection techniques or other forms of information technology 7 A copy of the draft supporting statement may be viewed free of charge at the NRC Public Document Room, 2120 L Street NW (lower level), Washington, DC.

Members of the public who are in the Washington, DC, area can access this document via modem on the Public Document Room Bulletin Board (NRC's Advanced Copy Document Library), NRC subsystem at FedWorld, 703-321-3339. Members of the public who are located outside of the Washington, DC, area can dial FedWorld, 1-800-303-9672, or use the FedWorld Internet addres : fedworld. gov (Telnet). The document will be available on the bulletin board for 30 days after the signature date of this notice. If assistence is needed in accessing the document, please contact the FedWorld help desk at 703-487-4608.

Additional assistance in locating the document is available from the NRC Public Document Room, nationally at 1-800-397-4209, or within the Washington, DC, area at 202-634-3273. ,

Comments and questions about the information collection requirements may be directed to the NRC Clearance Officer, Brenda Jo. Shelton, U.S. Nuclear

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Regulatory Comission, T-6-F33, Washington, DC, 20555-0001, by telephone at (301) 415-7233, or by Internet electronic mail at BJS19NRC. GOV.

DatedatRockville, Maryland,this)l day of /7 o y , 1997'. ;

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For the Nuclear Regulatory Comission, i

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Arnold E. Levin, Kcting Designated Senior -l

' Official for Information Resources Management t

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l Regulatory Commission, T-6-F33, Washington, DC, 20555-0001, by telephone at )

l (301) 415-7233, or by Internet electronic mail at BJS10NRC. GOV, i

l Dated at Rockville, Maryland, this 2/bayof M4 t > , 1997.

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For the Nuclear Regulatory Commission.

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_./ n Arnold E. Levin, Acfing Designated Senior

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Official for Information Resources l Management l i

Distribution: i HOLB R/F File Center i SWeiss, NRR l 1

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DOCUMENT NAME: C:\AUT0S\WP51\0MB0090

SEE 79tEV10VS CONCURRENCE Ts seceive e copy of thle elocument,insRcate in the ben: *C* a Copy without ettechenentlenclosure *E' s Copy with ettschmentlenclosure *N* a No copy 0FFICE OLB:DRCH:NRR E C:0LB:DRCH:NRR N DD:DRCH:NRR N D:DRCH:NRR N PIMB:NRR E NAME DMcCain* SRichards* LSpessard BBoger* RIngram*

DATE 04/28/97 04/29/97 04/ /97 04/29/97 05/1/97

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0FFICE IRMByIRM , , E OGC N IRM N NAME B h W 2 fL GFehst h h Alevin (/ %V DATE 05//j/97 V N 05//r /97 #_- 05/11/97 -

0F:ICIAL RECORD COPY

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DRAFT SUPPORTINC STATEMFNT 3

FOR '

NRC FORM 398, " PERSONAL QUALIFICATION STATEMENT - LICENSEE,"

10 CFR PART 55, 555.31, 55.35, 55.47 AND 55.57 (OMB Clearance No. 3150-0090)

Extension 4

DESCRIPTION OF THE INFORMATION COLLECTION ,

NRC Form 398 standardizes the essential information needed to apply or reapply for, or to renra an operator's license to operate a nuclear reactor.

A. ESTIFICATION

1. Need for and Practical Utility of the Collection of Information ,

The regulations in 10 CFR Fart 55, 555.31, 55.35, 55.47 and 55.57, specify the use of NRC Form 398 to collect information from licensees / applicants seeking to obtain licenses to operate nuclear reactors.

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2. Aaency Use of Information ,

i The completed NRC-Form 398 is reviewed against the licensing l

criteria to ensure that licensees / applicants meet all the requirements for taking the written examination or operating test;

recpplying because of failure to pass the written examination or operating test, or both; or renewing a previous license. The NRC Form 398 also provides certification by the authorized facility l representative that the licensees / applicants meet their requirements i to be licensed as operators, and of the facility's need for them to be licensed as operators.

The information provided on the NRC Form 398 is extracted by the regional / headquarters offices and keyed into the Operator Licensing l Tracking System data bank for tracking operator licenses and can be l used for generating reports on licensing actions and issuing license

< and denial letters. l

3. Reduction of Burden Throuah Information Technoloav )

H There is no legal obstacle to the use of information technology.

Moreover, NRC encourages its use; however, at the current time, no responses are submitted electronically. ,

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4. Effort to Identify Duplication and Use Similar Information This information is available only from the licensee / applicant and does not duplicate or overlap other information collections made by the NRC or other government agencies. The Information Requirements Control Automated System was searched and no duplication was found, l

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5. Effort to Reduce Small Business Burden This information collection does not involve any small businesses. .

6. Conseauences to Federal Prooram or policy Activities if the Collection is not Conducted or is Conducted Less Freauentiv ,

The-collection of information is occasional and is collected as needed.

7. Circumstances which Justify Variation from OMB Guidelines This information collection does not vary from OMB guidelines.

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

9. Payment or Gift to Respondents Not applicable.

10. Confidentiality of Information The NRC Form 398 is filed in the licensee's/ applicant's docket file.

The information is also placed in an NRC data base (Operator Licensing Tracking System). The information is not available for public inspection.

11. Justification for Sensitive Ouestions No sensitive information normally considered private is requested on NRC Form 398.

12. Estim.ated Industry Burden and Burden Hour Cost Approximately 600 new, 1000 renewal end 60 reapplications are )

expected to be submitted annue.11y.

I Applications for new licenses are to be submitted in total one time ;

I only and there is no pre-specified reporting period.

The first reapplication can be filed at least two months after the date of the denial letter. The second reapplication can be filed six months after the date of the second denial letter. Successive reapplication can be filed two years after the date of the third dental letter and the date of each prior application.

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1 Renewan applications are to be submitted no fewer than thirty days prior to the expiration of the existirg license. l

<. NRC Form 398 is required to be submitted to Headquarters or the appropriate Regional Office.

Records are not required to be retained by the licensees / applicants.

The estimated burden :.o complete the NRC Form 398 is 2 hours2.314815e-5 days 5.555556e-4 hours 3.306878e-6 weeks 7.61e-7 months per initial applicatis, .50 hours5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months per re&pplication and .50 hours5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months per renewal appli ui.fon. New applications take longer to complete, as it is the first cime 'the appropriate information is collected onto '

one form. After the initial application, the reapplication and renewals update specific relevant items. Estimates are based on past experience of the respondents' actual times to complete the NRC Form 398. ;

2 hours2.314815e-5 days 5.555556e-4 hours 3.306878e-6 weeks 7.61e-7 months x 600 new applications - 1,200 hours0.00231 days 0.0556 hours 3.306878e-4 weeks 7.61e-5 months x $128/ hour = $153,600 annually.

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.50 hour5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months x 60 reapplications - 30 hours3.472222e-4 days 0.00833 hours 4.960317e-5 weeks 1.1415e-5 months x $128/ hour - $3,840 1 annually.

.50 hour5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months x 1000 renewal applications - 500 hours0.00579 days 0.139 hours 8.267196e-4 weeks 1.9025e-4 months x $128/ hour -

$64,000 Total annual cost to industry - 1,730 hours0.00845 days 0.203 hours 0.00121 weeks 2.77765e-4 months x $128/ hour = $221,440

13. Estimate of Other Additional Costs None.

14. Estimated Cost to the Federal Government Approximately 600 new applications and 60 reapplications are expected to be submitted by licensees / applicants annually. These numbers are based on the data available from the Operator Licensing Tracking System. Processing the NRC Form 398 takes .75 hours8.680556e-4 days 0.0208 hours 1.240079e-4 weeks 2.85375e-5 months per new application and .50 hours5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months for each reapplication. The NRC form 398 processing includes data input, files maintenance and forms review regarding the eligibility criteria. Data input takes longer for new applications because all data must be entered initially, whereas for reapplication and renewals, the data base needs only to be updated. Estimates are based on staff experience.

600 new applicants x .75 hour8.680556e-4 days 0.0208 hours 1.240079e-4 weeks 2.85375e-5 months x $128/ hour = $57,600 annually i i

60 reapplications x .50 hour5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months x $128/ hour = $3,840 annually

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The renewal period of operators' licenses is six years.

Approximately 1000 renewal applications are expected annually.

Processing the NRC Form 398 for renewals takes .50 hours5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months for each application. As stated above, renewal applications take less time to compete than new applications because the data need only be updated. This estimate is based on staff experience.

1000 renewals x .50 hour5.787037e-4 days 0.0139 hours 8.267196e-5 weeks 1.9025e-5 months x $128/ hour - $64,000 annually.

Ccst for Operator Licensing ' racking System - $90,000 annually Therefore, the total annual cost to the Federal Government is expected to be $215,440 ($57,600 + $3,840 + $64,000 = $125,440 +

$90,000 = $215,440).

Cost to the government is fully recovered through fee assessments to NRC licensees pursuant to 10 CFA Parts 170 and/or 171.

15. Reasons for Chanaes in Burden or Cost The estimated burden remains the same.

16. P_ublications for Statistical use This information is not published for statistical use.

17, Reason for Not Disolavina the Exoiration DLte l The expiration date is displayed. !

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18. Exceptions to the Certification Statemrnt None. l B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS 1

Statistical methods are not used in this information collection. 10 CFR 55.31, 10 CFR 55.35 and 10 CFR 55.57 require that applicants use NRC Form 398 to apply or reapply for or renew an operator's license. l f

Enclosure:

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NRC Form 398 (XX/97)

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INSTRUCTIONS FOR COMPLETING NRC FORM 398, PERSONAL QUALIFICATION STATEMENT-4.lCENSEE TO REMAIN VAUD, THIS /ORM MUST NOT BE ALTERED

4. TYPE OF APPLK:ATION COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE

a. NEW - T IF YOU ARE A NEW APPUCANT.

INSTRUCTIONS BELOW. THIS IS TOINCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE SEE ' TEM 12- THERE IS AN EXCEPTION. ALSO, THLS BLOCK IS TO BE MARKED TO THE DATE OF THIS APPUCATION. NOTE:

IF PREVIOUS NEW APPUCATION WAS WITHDRAWN. PLEASE WRITE WITHDREW" NEXT TO "NEW.

FOR 4 b THROUGH 4 e. COMPLETE EACH CATEGORY COMPT ETELY. BUT INDICATE ONLY THE EDUCATION, TRAIN YOU HAVE RECEIVED SINCE YOUR LAST APPUCATION. NOTE: ME ITEM 12 THEREls AN EXCEPTION.

b. f ENEV.'AL-Tif YOU ARE RENEWING CURRENT UCENSE.

c. UPGRADE."X"lF YOU HOLD A RO UCENSE AND ARE NOW APPLYING TO UPGRADE YOUR UCENSE TO 4L MULTl4NT TIF YOU CURRENTLY HOLD A UCENSE AT YOUR FACILITY AND ARE APPL \ NG TO TO ADD AN ADDITIONAL UNIT.

e. REAPPUCAT40N "X"IF YOU HAVE PREVIOUSLY BEEN DEI ..ID / UCENSE AND ARE REAPPLYlNG.

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

g. DATE PASSED GENERIC FWDAMENTALS EXAMINATION SECTION (GFES) THIS IS NOT APPLICA UCENSES UMITED TO FUEL HANDUNG. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAM; NATI IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC UCENSING THE WRITTEN EXAMINATION WAS PASSED.

EXAMINATION ON THE APPUCABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982. WHICH LED TO THE A UCENSE. THIS DOES MQIINCLUDE INSTRUCTOR CERTIFIC, vie E"MINATIONS OR REQUAUFICATION EXAMINATlONS

11. EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAUTECHNICAL POST HIGH SCHOOL EDU STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE REC DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION,INCLUCING PROGRAMS SUCH AS NUCLEAR POWE MfDTARY TRAINING, AIR CONDITIONINGREFRIGERATION, DIESEL MECHANIC SCHOOL. ETC. INDICATE THE NUMBER OF MO PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED IF ADDITIONAL SPACEIS NEEDED, CONTINUE UNDER (ITEM 17).

12. FACERY OPERATOR TRAINihG PROGRAM CHECK THE APPROPRIATE BOV. IN ITEMS 12.a AND 12.b ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD.

NOTE: IF "YES* IS CHECKED IN BOTH ITEMS 12.a AND 12.b THEN ITEMS 13 (TRAINING),14 (EXPERIENCE), AND 15 (EXPERIENC DETAILS) DO NOT HAVE TO BE DOCUMENTED, WITH THE EXCEPTION OF BLOCK 13.3 c ALL NEW APPLICATIONS nT INCLUDE THE NUMBER OF SIGMFICANT CONTROL MANIPULATIONS WHICH AFFECT REACTIVITY

,13 3 c.

13. TRAINING ALL NEW APPLICATIONS MUST INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULA ,

REACTMTY OR POWER LEVEL UNDER ITEM 13.3.c. l ALL REQUAUFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUAUFICATION ITEM 13.6. l THE TIME SPENT IN REQUALIFICATION TRAINING FOR CLASSROOM OR SIMULATOR TIME UNDER ITEMS 13.1,13.2, OR 13.3.

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14. EXPOtlENCE A MINIMUM OF 6 MONTHS AT THE 6tTE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. Fj COMPLETE ITEM 15. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPtNG DUTIES, THE MONTHS SHOULD REFLECT THE :

PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE S MONTHS REPORTED FOR a PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT T i

18. EXPERENCE DETAE S INCLUDE POSITION TITLE, TIME PER)OD-FROMiTO, FACluTY, 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 ADDlTIONAL l INFORMATION.

16. FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR I FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT FACluTY REQUAUFICATION EXAMINATION.

17. COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON TH FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT,YOU MAY ATTACH EXTRA INFORMATION WIN YOUR APPUCATION. 1 i 18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION UNLESS A 1 WAIVER OF THE MEDICAL EXAMINATION IS BEING REQUESTED

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

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! DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 AND 396 (ORIGINAL AND TWO COPlES EACH) TO j APPROPRIATE REGIONAL ADMINISTRATOR. (SEE REVERSE SIDE FOP ADDRESSES OF REGIONAL ADMINISTRATORS AND FOR T1 ACT STATEMENT.)

NRC FORM 396 (WWW) l I

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ADORESSES OF REGIONAL ADMNSTRATORS

. I in scoorstence weh 10 CFR 56 5, Communicatens, ins form eheil be sutmtted to tr.e NRC es follows: BY MAIL ADDRESSED 70-REGIONAL ADMINISTRATOR, PEGION II REGIONAL ADMfMSTRATOR. REGCN fil '

REGIOJAL ADMIN 687RATOR. REGION I U.S. NUCLEAR REGULATORY COMMISSION U. S. NUCLEAR REGULATORY rmutSSION U.S. NUCLEAR REGULATORY COMMISSION ATLANTA FEDERAL CENTFM 801 WARRENVILLE ROAD 475 ALLENDALE ROAD LISLE. IL 80632-4351 KING OF PRUSSIA, PA 19406 1415 61 FORSYTH STREET,8.W., SUITE 23T85 ATLANTA, GA 30303 3415 U.S. NUCLEAR REGULATORY COMMISSION NON POWER REGIONAL ADMINISTRATOR. REGCN IV U.S. NUCLEAR REGULATORY COMMfSSON OPERATOR LICENSING BRANCH, NQ U. 8. NUCLEAR REGULATORY COMMf88CN NON POWER REACTORS AND DECOMMISSONING 811 RYAN PLAZA DRIVE, SUITE 400 DIVISION OF REACTOR CONTROLS AND ARL rNCTCN, TX 76011 4 084 HUMAN FACTORS PRCMECT DfRECTORATE. HQ WASHINGTON, DC 200664001 DIVISION OF REACTr1R PftOGRAM MANAGEMENT WASHINGTON, DC 200650001 PRIVACY ACT STATEMENT Ptsmart to U 8.C. 562e(e)(3), enacted into low by Secten 3 of the Privacy Act of 1974 (Pubhc Law 93479), the fonowing is fumiehed to indM infor.neton to the U.S. Nucteer RapM'wy Commiseson on NRC Form 396. This informehon is maintained in a System of Records deed 0neled as N I deserthed at 58 Federaf RegNefer 36405 (My 7,1993), or the most recent Federaf Repsfer pubscehon of the Nuedeer Reguietary Commseedon's of Systems of Records Nohces" that is eveilabio et the NRC Public Document Renm, Geomen Buildin0. Lower Level,2120 L Strost N

1. AUTHORITY. 42 U S.C. 2137 and 2201 (i)(1968).

2. PRDiCFAL PURPOSES. The information will be coNected and evolueted for determining licensing ehgetuilty and to generate stehetzel data and repo hoenomg actume.

3. ROLITBE USf28. Information entered on this form may be used to: (a) determine if the indMdual meets the redroments of 10 CFR Part 56 to be is on operator's Icense, (b) pnMdo resserchers with informehon for steheheel eveiuebons reisted to selechon, tramin0, and examinatiors of f pnMde tecAy managemart eth sultaunt Normebon b enrot you in the licensed operator requeh6cetion program; and (d) prov6de for ene ,

muertsiend ottom reeute Rom crirdrectors informehon may eleo be Man =<f to appmprtste Federed, State, local, or Foreign egencies to the extent relev l

and neceanery for en NRC dw=*=1 abond you or m the etert the informehon ind*stes e vinishnq or potential vloimbon of law. in addltion, in he h M tie course of en eenhistsee or gescdel procestgrqi, to a C.m ,; ofRce to respond to their inquiry made et your request, or to NCC-pent esporte, conmutante, and othere under contract with the NRC, on a need-to-know basis.

4. MSETMR DieCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDMDUAL OF NOT PROVENNG prORMATIDN. D=<*-re is vetureary Heester,if tw Harmenon r=t =*d le not provided, NRC wl0 ret be able to svolusts whether the apPenman meste the requirem Part 96.

6. SYSTEMS MANAGER (S) AM ADDRESS. CNef, Operstar Lkaneng Branch, DMeion of Ramrear tr=f=<*n and Ucensee Performance, ofnce of Nuclea Reactor Regulation, U.S. Nuoteer Regulatory Commiseenn, WesNngton, DC 20566 0001, i

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EXP1RES. educO.YYYT MBC FORM 300 U S NULLI AA RtGULATORY COMMISSION APPROYEDwTU409. NO.4lSf m 0 DATE RECElVID (To be c mpJeted by hMC)

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1. APPUC4NT'S FULL NAME (Last, fint. Meddle) AND ADDRESS Imclude llP Codel 4. TYPE OF APPUCATION (Check oppsrece teonesj l HOT l l COLD

, Ng w l f WAlVER REQUESTED f.lustr4 on Reverses b RtNEWAL 1. WRTTTT N (Co, ego,y; c , UPGRADE _

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s. PREVIOUS UCENSEISI HEE.D S. TYPE OF UCENSE APPUED FOR

e. OPtRATOR e DOCrET NUMBE R 80 anO b. UCENSE NUMBER Lh7" ,' , d F ACluTY DOCKET NUMBER

_ I I I b SEN80R OPERATOR L LIMittO SRO to g, fuel Mondner)

7. NAASE AND ADOftESS OF APPUCANT'S EMPLOYER (includellPCodel 10. CUfUIENT POSIT'#0N AT FAC8LTTY t AUXILIARY UNet OPE R a PLANT SUPERINTENDENT ATOR,TRAINE E/TUR8INE tt AS$1STANT PLANT SUPE RINTE NDENT SUILDING/E OUIPME NT OPERATOft (NON L1Cf NS

c. 5HIFT SUPtRVISOR (D OPERA TOR 8

d. STAFF INGINEE R f OTHER (Spec,4f e 6HIFT TECHNICAL ADVISOR /$HIFT E NGINt ER C. NAME OF APPUCANT'S F ACILTTY l F ACIUTY DOCKE T NUMBE R f INSTRUCTOR U. ADOf7DOfeAL FACfLTTY DOCMETS fMutts-unit Licensasi g SE NIOR CONTROL ROOM OPERATOR h CONTROL ROOM OPERATOR l

11. EDUCATION huMet A U

s. HeeMSCHOOL e. AAAJOR AREA (Si OP STUOV f,h @,' DEGREE CODES d. VOCAflONAL/ TECHNICAL up ne c I

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12. FACIUTY OPEftATOft Y*="*88 PItOGIRAtt :

e if*O ACCRtorTED OP% RAT 0lt TRAlfeNG b Ct #flFeD IO8e te,nC POMM ess *$deVLa rK1Af f ACA17Ycowwww onYES NO uste APenovao sesotarios eAcitrrY PROGAAM THAT IS SA900 UPON A SY$TEMS YE$ NO ustD se f>E OptRAfon rnAmsNo enuGRAM

MP40ACM TO TRAseNG =

13. TRACN3909 (SINCE LAS T APPtlCA TION - SEE INSTRUCTIOlVS) 14. EN8*99tlENCE IDO NOT DOUSLE COUN T - SU INS TRUCTIONSI i NN[FIv'Os' mAvv

~Y Th SeM 1 - NUCLI AR POWt A PLANT FUNDAMENT ALS U l RO 2 - PLAN T SYSit MS 2 . EOOW4*PWO CLASSROOM ,

08S8 RVATION

4. E RS/CRW 8 3 - OPE RATING PRALT ,f 6. OTHER f5perd4)

CONTPOt ROOM opt RATIONS ON SHIFT POsteL SIMULATOR OPE RATINQ ikwfudes CJeser orni I 4

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la NRC PORM SOS, CSRTIFICATIOAI Op aamcar EXAAAINATIORI BY FACIUTY UC5BISSE,IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CML AND CRIMINAL SANCTIONS.

198. 8 certify under moneWy of perjury that the enformaten in the document end attachments m true end correct ' further rettify that I have notified my curren

- any enstance veteore i have been fossied by a Health and Human Serv 4ces IHHS) Cartsteed Drue Tes"g Lateoratory or a Licensee o taanng facilvty for alco roeutts exceeded the estoft levele estacleshed pursuant se to CFR Part 26,(31 any instarre where t keve been arrestad for the sale, use or r . .

Part M. and 141 eny reasons har removal or revocanon of unescoded access at a nuclear facality,I also authorus the NRC to evbmat the results of enemmahone to my ornploye retrasneng programs, as n. - ry.

l DATE SIGNATURE-APf'LICANT CueCu APPuCAsta sox D 0 cortefy that the above stamed endnndual has successtusy completed the facihty hcensees requerements to be incensed as an Operator /Seneur Operato fleguietsons Port M, and that the ind6vidual has a need for an Operator!Sernor Operator hcorne to perform hasdier essegried duties and that the facihty evill be m I also sortefy under penalty of perhary that the information in this ^-- -- and eu. nte e true and sorrect.

s. flENEWAL ONLY + lsortify that the above named endsvedual eneets the approved requelsfication program (weth saceptsons noted in / tem f /J as requered by sectio r

that he/she hee descharged hugher licensed reopensetwitties competently and sa ely. I ateo certdy under penefty of perjury that pse ardormahon in this doc aviachments is erve end correct.

TRAINIB06 Pd"-aTOR l 300lIOR RAANAGERAS$ff REPRESENTATWE ON SITE ,

PRINTED OR TYPED NAME AND TITLE PRINTED OR TYPED NAME ANO TITLE.

SIGNATURE SIGNATURE lDATE lDATE FOR MIIC USE A l l DOES h0T MEET REQUIRtMENTS (f apism below)

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Text

SUMMARY

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