ML20214S634
| ML20214S634 | |
| Person / Time | |
|---|---|
| Site: | Yankee Rowe |
| Issue date: | 06/04/1987 |
| From: | Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Heider L YANKEE ATOMIC ELECTRIC CO. |
| References | |
| NUDOCS 8706090351 | |
| Download: ML20214S634 (17) | |
Text
_ _ _ _ - _ _ _
Docket No. 50-29 Jg 4g Yankee Atomic Electric Company ATTN: Mr. L. H. Heider Vice President of Operations 1671 Worcester Road Framingham, Massachusetts 01701 Gentlemen:
Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualif-ications Statement - Licensee.
This revision was made to reflect the changes to 10 CFR Part 55 effective May 26, 1987.
This revised form requires new applicants to complete each category completely including all education, training and experience received up to the date of the application.
Renewal, upgrade, multi-unit and reapplication applicants are required to complete each category except they need only to indicate the educa-tion, training and experience received since their last application.
If any applicant indicates that he or she is a graduate of an INP0 accredited operator training program AND that an approved simulation facility, i.e.,
(certified on NRC Form 474 or NRC approved), is used in the operator training program, then education, training and experience DOES NOT have to be completed.
New applications must include the number of significant control manipulations under Item 12.3.
Other changes are detailed in Enclosure 2. is a set of instruc-tions for the completion of all items on the NRC Form 398.
All applications for licenses are to be submitted on this revised form begin-ning May 26, 1987.
1 The enclosed applications are for your use. Additional copies can be obtained by writing to Vivian Miller, U.
S.
Nuclear Regulatory Commission, Document Management Branch, Mail Stop W-548, Washington, D.C. 20555.
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If you have any questions regarding this form, please contact Robert M. Keller at 215-337-5211.
Sincerely, Original Signed By,s Samuel J. Collins, Deputy Director Division of Reactor Projects
Enclosures:
As stated cc w/ enclosures:
C. Russell Clark, Training Manager Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector Commonwealth of Massachusetts (2) cc w/o enclosures:
N. N. St. Laurent, Plant Superintendent J. E. Tribble, President G. J. Papanic, Jr., Senior Project Engineer - Licensing NRC Resident Inspector bec w/ enclosures:
OL Plant File Examiners RI:DRP RI:
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C lins 6/+ 87 b/ k7 6/h/87 0FFICIAL RECORD COPY OL MULTI LTR - 0044.0.0 05/29/87
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INSTRUCTl3NS F01 COMPLETING J,
NRC FORM 338. PERSONAL QUALIFICATIONS STATEMENT-LICENSEE NEW APPUCANTS. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE INSTRUCTIONS BELOW. THIS is TO INCLUDE ALL EDUCATION. TRAINING AND EXPERIENCE THAT YOU HAVE RECE1VED UP TO THE DATE OF THis APPUCATION. NOTE: See item 14.
EENEWAL. UPGRADED. MULTI UNsT. AND REAPPUCATION APPUCANTS. COMPLETE EACH CATEGORY OF FORM COMPLETELY. EXCEPT INDICATE ONLY THE EDUCATION, TRAINING. AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPUCATION. NOTE: See stem 14.
SPECIFIC INSTRUCTIONS FOR ITEMS 1119:
11-EDUCATION: INDICATE BOTH ACADt:MIC AND VOCATIONALITECHNICAL POST HiGH SCHOOL EDUCATION. FOR MAJOR AREAISI OF STUDY.
INDICATE THE NUM8ER 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 MlUTARY TRAINING. AIR CONDITIONING / REFRIGERATION. DIESEL MECHANIC SCHOOL. ETC. INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OFI DEGREE WAS AWARDED. IF A00lT60NAL SPACE IS NEECED. CONTINUE UNDER ITEM 17.
12-TRAINING; IN THIS ITEM INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1. THE l
BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS: PLEASE REFER TO THE STANDARDS IF YOU NEED FURTHER I
CLARIFICATION. tNC UCE 80TH BEGINNING AND COMPLETION DATES AND THE TOTAL NUM8ER OF WEEKS SPENT IN EACH TYPE OF TRAIN.
ING. NUMBER OF WEEKS IS PROVIDED. IN ADDITION TO BEGINNING AND COMPLETION CATES. TO ACCOUNT FOR INTERMITTENT TRAINING IFOR EXAMPLE. 80UR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERICOI. THEREFORE. THE DATE COLUMNS MAY IN-CICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL TIME TRAINING. TIME IN TRAINING FOR THE UCENSE APPUED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.
ALL RECU AUFICATION TRAINING TIME IS TO BE ACCOUNTED FOR iN THE REQUAUFICATION ITEM. PLEASE AVolo " DOUBLE USTING" RECORD-ING ALL THE TIME SPENT IN REQUAUFICATION TRAINING UNDER ITEM 12.6. REQUAUFICATION. EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME.
13-EXPERIENCE: FOR EACH POSITION HELO. COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING OUTIES. THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERICO EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.
14-FACluTY OPERATOR TRAINING PROGR AM. iN0iCATE
- a. GRA00 ATE OF INPO ACCRE0fTED OPERATOR TRAINING PROGRAM: AND b.CER.
TIFIED ION NRC FORM 4741 OR NRC APPROVED SIMULATION FACIUTY IS USED IN THE OPERATOR TRAINING PROGRAM. IF YES IS CHECKED IN BOTH ITEMS a AND b. THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCF AND 16 FXpFRIFNCF OFTAILS no NOT H AVE TO BE COMPLETEC; EtCEPT NfM APPUCATICx3 4 5T STILL IMLUCI TnE Nm8ER OF 11CN!FICANT CONTROL PWi1PULATIONS UNDER ITEM 12.3.
NOTE: INPO ACCRE0lTED MEANS ACCREDITATION SY THE NATIONAL NUCLEAR ACCREDITING BOARD.
15-FOR RENEWALS ONLY: ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF UCENSE IF FIRST I;ENEWAL.
16-EXPERIENCE DETAILS: INCLUDE POstTION TITLE. TIME #ERICD FROM/T4FACTUTY. AND A BRIEF DESCRIPTION OF QUTIES PERFORMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEr.CEO USE ITEM 17. OR IF NECESSARY ATTACH ADDITIONAL INFORMATION.
17 COMMENTS: USE THIS SPACE TO !NCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPUCATION FORM.
IF THE SPACE PROVIDED 15 NOT SUFFICIENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.
10-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION BY FACluTY UCENSEE. MUST ACCOMPANY THIS APPUCATION.
19-$1GNATunES: SIGN AND DATE ITEM 19a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGE.
MENT REPRESENTATIVE ON SITE.
OETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 396. IN TRIPUCATE (onganaland two coo est AND 396 TO THE APPROPRIATE REGIONAL ADMINISTRATOR.
PRIVACY ACT STATEMENT Pursuant to U.S.C. SE2a(ell 31. enacted into law by Section 3 of tre Pnvecy Act of 1574 IPublic Law S3-5791. the following is furnished to in-dividuele who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 396. This information is mamtemed in a system af recorde designated as NRC 18 and desenbod at e6 Federal Register 46717 ISeptember 21.1961).
- 1. AUTHORITY. Section 107 and 161til of the Atomic Energy Act of 1964, se amended 142 U.S.C. 2137 and 2201 till.
- 2. PRINCIPAL PURPOSES. The informenon will be collected and eva6usted for determining licenomg eligibility and to generate statistical data and reporte on licenseng actione.
- 3. ROUTINE USES. Information entered on thee torm may be used to: Isl determine if the individual meets the requirements of 10 CFR Part 55 to be issued en operator's license: (b) provide researchere w.th information for statistical evaluatione related to selection, trainmg. and eneminatson of f acitety operatore:Icl provide acility management with sufficient informetion to enroll the individuals in the liconeed operator r
requalification program: (d) provide for exa nination and testing matenal and obtain resulte frow contractors.
- 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNT AkV AND EFFECT ON INDIV10U AL OF NOT PROVIDING INFORM ATION: Disclosure I
is vo6untary. However. if the information requested is not provided. NRC will not be able to evolvate whether the application meets the requiremoets of 10 CFR Part $6.
- 5. SYSTEMS MANAGERS AND ADDRESSES:
Regional Aomnetrator. Rep i Regional Admarustrator. Regen !!
U S. Nuclear Regusatory Commess.on U.S. Nucnear Regulatory Commesson 631 Part Avenue 101 Mergtta Street. Suite 2900 King of Prussaa. PA 19406 Attants. GA 30323 Regional Adminrstrator. Reg.on ill Regenal Admnstrator. Region IV Regional Admastrator. Regon V U.S. Nuclear Regulatory Commession U.S. Nucmar Regulatory Commrssson U.S. Nucieer Regulatory Commisson 799 Roosevelt Road 611 Ryan Pieza Onve. Su.te 1000 1450 Mana Lane. Suite 210 Geen Elfvn. IL 60137 Art.ngton. TX 76011 Wainut Creest. CA 94596
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ENCLOSURE 2 I
SUMMARY
OF CHANGES TO NRC FORM 398 Moved "New" to below " Hot" and " Cold". '
Item 4.a Combined " Oral" an'd " Simulator" into " Operating". -
Item 4.f Item 5.d Deleted " Instructor Certification".
Itera 14 Added a new item " Facility Operator Training Program" and incorporated under this item the INPO accreditation block (originally under Training);
added a block for NRC approved or NRC Fom 474 certified simulation facility.
Item 15 Added a new item "For Renewals Only Hours Operated Facility". (This was originally under Experience).
Items 16 Renumbered previous items 14 through 17 to 16 through 19 through 19.
Item 18 Changed to read "NRC Fom 396, Certification of Medical Examination by Facility Licensee is attached" to indicate that in order for the application to be complete the NRC Form must be attached.
Any false statement or omissions in this document, Statement Added including attachments, may be subject to civil and criminal sanctions.
Changed the wording to read "... certify under Item 19.a penalty of perjury that the infomation in this document and attachments is true and correct. I also..."
Changed the wording to read "... has Item 19.b successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant..." Also added the wording "I also certify under penalty of perjury that the l
infomation in this document and attachments is true and correct." Changed signature block from
" Highest Level Of Corporate Management for Plant Operation" to " Senior Management Representative On Site."
Added the wording "I also certify under penalty Item 19.c l
l of perjury that the infomation in this document and attachments is true and correct. Changed signature l
block from " Highest Level of Corporate Management i
for Plant Operation" to " Senior Management l
Representative On Site."
l Under waiver category combined " Oral" and FOR NRC USE
" Simulator" into " Operating".
ENCLOSURE 3
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PERSONAL QUALIFICATIONS STATEMENT - LICENSEE NRC FORM 398 (REV 4/87)
NEW APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 COMPLETELY, FOLLOWING INSTRUCTIONS BELOW.
THIS IS TO INCLUDE ALL EDUCATION, TRAINING, AND EXPERIENCE THAT APPLICANT HAS RECEIVED UP TO THE DATE OF THIS APPLICATION (NOTE EXCEPTION:
SEE ITEM 14).
RENEWAL, UPGRADE, MULTI-UNIT AND REAPPLICATION APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 EXCEPT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE RECEIVED SINCE LAST APPLICATION (NOTE EXCEPTION: SEE ITEM 14).
4 A SEPARATE NRC FORM 398 FORM MUST BE SUBMITTED EACH TIME AN APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.
FULL NAME AND CURRENT ADDRESS.
ITEM 1 CITIZENSHIP.
If other than U.
S. Citizen, ITEM 2 citizenship must be specified.
DATE OF BIRTH.
ITEM 3 TYPE OF APPLICATION.
ITEM 4 "X" appilcable boxes:
1-Hot
- Applying for a license at a plant that has achieved initial criticality.
This should be completed for each appilcation.
2-Cold
- Applying for a license at a plant that has not achieved initial criticality. This should be completed for each appilcation.
e.
New
- Applying for the first time at this facility OR If previously applied for a license but withdrew (write in "previously withdrew
- next to New).
ALL ITEMS MUST BE COMPLETED ON A NEW APPLICATION AND SHOULD INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE RECEIVED UP TO THE DATE OF THIS APPLICATION.
THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.
i
w
.' b. Renewal Now holds a license and is renewing that same type of Ilconse.
ALL ITEMS MUST BE COMPLETED ON A RENEWAL APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE THE LAST APPLICATION.
THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.
Now holds an operator's
- c. Upgrade license and is applying for a senior operator's license.
ALL ITEMS MUST BE COMPLETED DN AN UPGRADE APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE APPLICANT RECEIVED SINCE LAST APPLICATION.
THERE IS AN EXCEPTION TO THIS -
SEE ITEM 14.
Applying for a license on d.
Multi-unit more than one unit OR is a licensed operator on one unit and is applying to
^
extend license to additional units.
(Notes all facility docket numbers are to be listed under Items 8 and 9).
ALL ITEMS MUST BE COMPLETED ON A MULTI-UNIT APPLICATI0H BUT NEED ONLY INCLUDE THE EDUCAT20N, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATION.
THERE IS AN EXCEPTION TO THIS -
SEE ITEM 14.
Previously took a licensing e.
Reappilcation exam and was denied a license and is now reapplying for that same type of Ilconse at the same facility.
The reappilcation should identify those areas in which the applicant demonstrated weaknesses during the previous examination and the additional training received to correct these specific deficiencies in Item 12.7 and/or Item 17.
ALL ITEMS MUST BE COMPLETED ON A REAPPLICATION APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATION.
THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.
,' 1-First-
- If denied a license for the first time, the applicant must wait two months from the date of denial letter before reapplying for a license.
2-Second If denied a license for i
the second time, the appilcant must wait six months from the date of denial letter before reapplying for a license.
3-Third If denied a license for the third time, the applicant must wait two years from the date of denial letter before reapplying for a license.
- f. Walver Request
- NOTE:
Justification for any waiver request is required under Item 17.
1-Written
- To request a walver on entire written exam or on part of the written exam.
(Category (s) for which waiver requested should be specified in space provided.)
2-Operating
- To request a waiver on an operating exam.
3-Eligibility
- To request a waiver on eligibility requirements.
4-Other
- To request any other waiver, i.e.,
medical.
ITEM S TYPE OF LICENSE APPLIED FOR
- a. Operator
- Applying for en operator license.
b.
Senior Operator
- Applying for a senior operator license.
- c. Limited SRO
- Applying for a limited senior operator license (e.g. fuel handler).
ITEM 6 PREVIOUS LICENSE (S) HELD
- To be completed if previously
)
held a license (or instructor certificate).
a.
Docket Number
- Docket number assigned for previous license (s) held (SS-XXXXX).
Indicate if this license was for RO or SRO.
If this was for
4 Instructor Cortificotton er Limitod Senior Operator, please write in.
If a denial letter was issued, a docket number was assigned and should be Indicated in this block.
f b.
License Number
- License number (s) previously held.
License number should include the present renewal number, if any, (i.e., XXXXX-3).
- c. Expiration Date Date of Ilconse expiration.
If several renewals have occurred, list only latest expiration date.
- d. Facility Docket No.
- Docket number of facility where applicant held license (50-XXX).
Note If previously held license / instructor certification at a training center, simulator, etc.,
where there is no facility docket number, write in the name.
NAME OF APPLICANT'S EMPLOYER ITEM 7
- Name and address of current employer.
ITEM 8 NAME OF APPLICANT'S FACILITY
- Name and docket number (50-XXX) of facility where applyino for a license.
ITEM 9 ADDITIONAL FACILITY DOCKETS If applying for multi-unit Ilcense ALL appilcable additional docket numbers must be entered.
ITEM 10 CURRENT POSITION AT FACILITY a.
Plant Superintendent Note license type if required by position.
b.
Assistant Plant Superintendent Note license type if required by position.
Position requires current
- c. Shift Supervisor senior license for a plant with fuel in the reactor, d.
Staff Engineer
- Note license type if required by position.
e.
Shift Technical Advisor / Shift Engineer-Note license type if required by position.
Note license typa if required f.
Instructor by position.
. ~
g.
Senior Control Room Operator
- Position requires current senior license for a plant with fuel in the reactor.
h.
Control Room Operator - Posit'lon requires current operator license for a plant with fuel in reactor.
- l. Auxillary Unit Operator / Trainee /
Turbine Building /
Equipment Operator (non-licensed operator)- Ensure description is detailed enough to allow evaluation of position.
J. Other (Specify)
- Ensure description is detailed enough to allow evaluation of position.
Note license type if required by position.
ITEM 11 EDUCATION a.
High School Graduate
- Graduated from high school.
GED Equivalency
- Received GED equivalency.
No
- Did not complete high school.
b.
Number of Years of College
- Number of years of college successfully completed.
(Freshman = 0 to 1 year Sophomore = 1 to 2 years Juniors 2 to 3 years Senior = 3 to 4 years Graduate = 4 years or more)
- c. Major Arests) of Study-Engineering
- Fleid of engineering majored in; number of years, ands highest degree obtained.
Other
- Other field majored ini number of years, and; highest degree obtained.
d.
Vocational / Technical Type of Training-Vocational / technical training schools, including allitary schools, appilcable to the operation of a
6-pswar plcnt.
Includo such
' programs as nuclear power school, s'ir conditioning / refrigeration school, diesel mechanic school, instrumentation and control maintenance, etc.
Number of Months-Calculate the approximate number of full months appilcant received actual training.
(4 weeks, 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> / day = 1 month)
Certificate Received
- Indicate if certificate was received for this training.
ITEM 12 TRAINING
- Training is Indicated in weeks based upon 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> per week.
Indicate training received to meet the requirements of ANSI N18.1/ANS3.1.
The breakdown below parallels the ANS standards.
Beginning and completion dates and the total number of weeks spent in each type of training must be included.
The number of weeks is provided to account for intermittent training (for example, four weeks of classroom training spread over a two month period).
Therefore, the date column 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.
REQUALIFICATION training time is be accounted for in Item 12.6, 1-Nuclear Power Fundamentals (Classroom)
- Fundamental course that covers the theory of the nuclear fission process and reactor operations.
2-Plant Systems
- Systems instruction to include both observation and classroom work.
This instruction is plant specific.
Classroom
- Instruction covering nuclear power plant systems and system and component malfunctions.
Observation
- Planned systematic observation training on accessible plant equipment.
3 3-Operating Practice Training in operating practices In the control room for which the candidate will license and at a plant i
referenced simulator if one is available.
Control Room Operations Observation of the operating practices and the operation of nuclear power plant from the central control room.
Hot Ilconse candidates must manipulate the controls under direct supervision of a licensed operator at the Individual's duty station for a variety of plant operations.
Cold license candidates are to participate in the plant preoperational testing program.
Actual time assigned to the operating shift should be counted in 12.5 below.
Simulator Operations (includes Classroom)
Practice in manipulating plant controls during normal, abnormal and emergency conditions on a plant referenced simulator.
Simulator Name(s)
Specify the simulator (s) where training was received.
If more than two simulators specify the two most recent only.
Startup Certification "X" Yes or No.
(Notes For Completed i
facilities with plant referenced simulators, certification cf startup training ul11 be provided by the facility organization.
For those facilities without a plant referenced simulator, startup certification must be obtained from the organization at which the startup demonstration was performed.)
Number of Reactivity j
Number of actual reactivity Manipulations:
manipuistions in which the applicant I
was involved broken down by plant and simulator.
(Details should be provided in Comments, Item 17.)
Instruction in the duties of 4-SRO Instruction a senior operator.
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8-5-Extra Person on Shift - Must be a minimum of three months on shift performing the actual duties of the licensed position applied for.
These duties are performed under the direct supervision of licensed personnel on normal shift rotation.
This should be in a structured, documented program.
Do not double count this time in 12.3 or as operating experience.
6-Requalification
- ALL requalifications training, including classroom and simulator time.
7-Other (Specify)
- Ensure description is detailed eno: -h to allow evaluation.
Inc.ede number of research reactor startups, if performed.
ITEM 13 EXPERIENCE
- Experience is Indicated in months.
For each position held, list the month / year to cover the period you were quellfled for that position.
The number of months must reflect the time spent actually exercising the respon-sibilities of that position.
Item 16 should be completed for each position held.
DO NOT DOUBLE COUNT TIME.
If there were overlapping duties, the number of months should reflect the proportionate i
amount of time assigned to those particular duties.
In no case should the number of months reported for a particular i
time period exceed the number of months that are in that time period.
Also, do not count time In training.
Military nuclear power experience should be listed in 1-5.
NAVY Non-nuclear allitary power experience should be listed under Fossil 6-9.
Qualified to operate the controls of a 1-RO Navy Propulsion or training reactor.
Authorized to supervise the operation of 2-E00W/PPWO l
Navy Propulsion plants.
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3-EWS/PPWS Oualified to direct and supervise the operations of a Navy Propulsion plant.
4-ERS/CRW Quellfled to direct and supervise Navy Propulsion plant operations outside the maneuvering area.
5-0THER (Specify)
Ensure description is detailed enough to allow evaluation.
FOSSIL 6-Operator Navy or commercial non-nuclear propulslon/ power plant operation.
7-Supervisor Authorized to direct and supervise non-nuclear operators.
8-Plant Staff Non-nuclear power plant staff experience.
9-Other (Specify)
Ensure description is detailed enough to allow evaluation.
COMMERCIAL NUCLEAR (Including Research/ Test Reactor) 10-Reactor Operator (Licensed)
Must hold or have held valid NRC operator license.
11-Senior Operator (Licensed)
Must hold or have held valid NRC senior operator license.
i 12-Shift Supervisor (Licensed)
Must hold or have held valid NRC senior operator license.
13-Staff / Shift Engineer (Licensed)
Must be at the facility and
)
involved in the day-to-day i
plant operational (engineering) staff work.
14-Aux./ Equip. (Nonlicensed)
Operator Personnel used in direct support of plant operations as directed by licensed operators.
15-Plant Staff Staff work other than that directly associated with plant operations.
Ensure description is detailed 16-Other (Specify) enough to allow evaluation.
ITEM 14 FACILITY OPERATOR TRAINING PROGRAM If "Yes" is checked in BOTH a) and b) then Items 11 (Education),
i 12 (Training), 13 (Exporlence), and 16 (Experience Details) DO NOT l
have to be completedi except new applications must still include the number of significant control manipulations under Item 12.3.
.-0
10 -
a) Graduate of INPD Accredited Operator Training Program "X" Yes or No if the applicant is a graduate of an INPO accredited 4
operator training program.
(NOTE:
INPO accredited means accreditation by the National Nuclear Accrediting Board.)
1 b) Certified on NRC Form 474 (Simuistion Facility Certification) or NRC Approved Simulation Facility is Used in the Operator Training Program "X" Yes or No if, in the operator training program, a certified on NRC Form 474 or NRC approved simulation facility is used.
ITEM 15 -
FOR RENEWALS ONLY - NOURS OPERATED FACILITY:
- The approximate number of hours appilcant has operated the facility under his existing Ilconse.
)
ITEM 16 EXPERIENCE DETAILS
- Include position title, time period (from/to), and description of duties performed while serving in that position.
Item 17 i
should be used if more space is needed.
ITEM 17 COMMENTS
- This space should be used to complete information from previous
)
items or clarification for other j
ltems on the application form.
If space provided is not sufficient, 1
extra pages may be attached to appilcation.
4 ITEM 18 NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE
- Any appilcatior; for a license or renewal of Incense is not complete without NRC Form 396.
l A medical is good for six months from the date the physician signs l
it.
For appilcations following a voluntary withdrawal or license denial or an upgrade appilcation, waivers may be granted on a case basis 11 the original medical evaluation was performed within one year.
If waiver is requested, Item 4.f.4 should be marked.
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ITEM 19
- SIGNATURES REQUIRED Any false statement or ommission in this document, including attachments, cay be subject to civil and criminal sanctions.
- c. Date and signature of appilcant certifying under penalty of perjury that the information provided on NRC Form 398 is true and correct.
Appilcant's signature also authorizes the NRC to submit results of examinations to appilcant's employer.
b.
Date and signature of Training Coordinator AND Senior Management Representative on Site certifying, under penalty of perjury, that applicant has successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant to 10CFR553 and that the applicant has a need for this license to perform assigned duties.
Also certifies that facility will be available for examinations.
- c. RENEWAL ONLY - Must be signed and dated by Training Coordinator AND Senior Management Representative On Site certifying, under penalty of perjury, that appilcant meets the approved requalification program (with any exception noted in Comments, Item 17) as required by section 50.54(I-1) of 10CFR50 and has discharged licensed responsibilities competently and safely.
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