ML20214S681

Forwards NRC Form-398, Personal Qualifications Statement- Licensee, for Operator Training Applicants & re-applicants to Complete,Per 870526 Rev to 10CFR55.Graduates of INPO & Approved Simulation Facility Do Not Have to Complete Form

ML20214S681
Person / Time
Site:	Indian Point
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Josiger W POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
References
NUDOCS 8706090368
Download: ML20214S681 (17)

Text

y .

w JUN 4 1987 Docket No. 50-286 Power Authority of the State of New York Indian Point 3 Nuclear Power Plant ATTN: Mr. William Jostger Resident Manager P. O. Box 215 Buchanan, New York 10511 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 applicatic .

If any applicant indicates that he or she is a graduate of an INPO 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. Enclosure 3 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.

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, 8706090368 870604 f PDR y

ADOCK 05000286 PDR ]g k I

0FFICIAL RECORD COPY OL MULTI LTR - 0033.0.0 I

05/29/87 i

k Power Authority of the State of New York 2 If you have any questions regarding this form, please contact Robert M. Keller at 215-337-5211.

Sincerely, OriB inal Signed Byg Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As' stated cc w/ enclosures:

B. Ray, Training Manager Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector cc w/o enclosures:

L. W. Sinclair, Presideat J. P. Bayne, First Executive Vice President and Chief Operations Officer J. C. Brons, Senior Vice President - Nuclear Generation A. Klausmann, Vice President - Quality Assurance F. X. Pindar, Quality Assurance Superintendent G. M. Wilverding, Chairman, Safety Review Committee M. Blatt, Director, Regulatory Affairs (Con Ed)

NRC Licensing Project Manager State of New York (w/ enclosures)

Gerald C. Goldstein, Assistant General Counsel bec w/ enclosures:

OL Plant File Examiners RI: :P RI I- P La Ke r o lins

[mjd/geb-f/ 87 h/ 7 6/S/87 0FFICIAL RECORD COPY OL MULTI LTR - 0034.0.0 05/29/87

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e INSTRUCTIONS FOR COMPLETING

' NRC FORM 398. 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 RECEIVED UP TO THE DATE OF THIS APPUCATION. NOTE: See item 14.

CENEWAL. UPGRADED, MULTI-UNIT, 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 nem 14.

SPECIFIC INSTRUCTIONS FOR ITEMS 1119:

11-EDUCATION: INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREAIS) CF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED. USING THE DEGREE CODE PROVIDED. FOR VOCATIONAUTECHNICAL 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 OR DEGREE WAS AWARDED. IF ADDITIONAL SPACE IS NEEDED. CONTINUE UNDER ITEM 17.

92-TR AINING: IN THIS ITEM 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: PLEASE REFER TO THE STANDARDS IF YOU NEED FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAIN.

ING. NUM8ER OF WEEKS IS PROVIDED. IN ADDITION TO BEGINNING AND COMPLETION DATES. TO ACCOUNT FOR INTERMITTENT TRAINING IFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERIOOL THEREFORE, THE DATE COLUMNS MAY IN.

DICATE 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.

GLL REQUAUFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUAUFICATION ITEM. PLEASE AVOID " 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.

93-EXPERIENCE: 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 SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

14 FACIUTY OPERATOR TRAINING PROGRAM. INDICATE a. GRADUATE OF INPQ ACCREDITED OPERATOR TRAINING PROGRAM: AND b.CER-TIFIED (ON NRC FORM 4741 OR NRC APPROVED SIMULATION FACIUTY IS USED IN THE OPERATOR TRAINING PROGRAM. IF YES IS CHECKED IN SOTH ITEMS e AND b. THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCE AND 18 FXPERIFNCF DETAILS 00 NOT wave TO BE COMPLETED; Ex IPT NEW APFuCATICM $$T STILL th;LUCI THE NUMBElt OF SIGNIFICANT CONTit0L MAN!PULATIONS UNDEli ITEM 12.3.

NOTE: INPO ACCREDITED MEANS ACCREDITATION SY THE NATIONAL NUCLEAR ACCREDITING BOARD.

15-FOR RENEWALS ONLY: ENTER THE APPROXIMATE NUMBER OP HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF UCENSE IF FIRST R ENEWAL.

14-EXPERIENCE DETAILS:!NCLUDE POSITION TITLE. TIME PERIOD FROM/TQFACIUTY. AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE 1ERVING IN THAT POSITION IF MORE SPACE IS NEEDED USE ITEM 17. OR IF NECESSARY ATTACH ADDITIONAL INFOP.MATION.

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

IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.

16-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION SY FACluTY UCENSEE. MUST ACCOM*ANY THIS APPUCATION.

19-SIGNATURES: SIGN AND DATE ITEM 19a. OSTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGE-MENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SU8MIT THE COMPLETED NRC FORMS 398,IN TRIPUCATE Ionganaland two cooseef AND 396 TO THE APPROPftlATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. 562aleH21. enacted into law by Section 3 of the Privacy Act of 1974 (Public Law $3-579), the following is furnished to in-dividuate who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. This information is meintained in a system of recorde designated as NRC 18 and described at 46 Federal Register 45717 (September 21,1981).

1. AUTHORITY. Section 107 and 161111 of the Atomic Energy Act of 1964, se amended (42 U.S.C. 2137 and 2201 till.

2. PRINCIPAL PURPOSES. The infor..~non will be collected and evaluated for cetermining licensing eligibility and to generate statistical data and reports on licenomg ecgene.

3. ROUTINE USES. fnformatioit entered on this form may be used to: (al cioWae if the individual meets the requirements of 10 CFR Part 5 to be inaued en operator's license: lbl provide researchere with information for statistical evaluations related to selection, training, and examination of f acilrty operators:(cl provihfacility menegament with sufficient information to enroll the individuale in the licensed operator requalification program: (d) provide for examination and testing metenal and obtain results from contractors.

d. WHETNER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORM ATION: Disclosure is voluntary. However, if the information roguested is not provided. NRC will not be able to evaluate whether the application meets the requirements of 10 CFR Port 55.

5. SYSTEMS MANAGERS AND ADDRESSES:

Regional Adminestrator. Region i Regiones Administrator, Region 18 U.S. Nucisar Regulatory Commenen U.S. Nuclear Regulatory Commession 631 Part Avenue 101 Meretta Street. Suete 2900 King of Prussas. PA 19406 Atlanta. GA 30323 Regonal Aaministrator. Regen til Regional Admin.strator. Regen IV Regional Admemstrator. Regon V U S. Nuclear Roguetory Commession U.S. Nucisar Requietory Commiesson U.S. Nuclear Regutatory Commesson 799 Roosevett Road 611 Avon Ptata Derve. Suite 1000 1450 Mare Lane. Suite 210 Glen Ellyn. IL 60137 Artington. TX 76011 Wainut Csees. CA 94596

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• N '0" 8 388 U. S. NUCLEAR REQULATORY COMMISSION '"*** 3 Q saares s aim

$'dlCaivso (Ts ee eemPWree AN .N

. == - PERSONAL QUALIFICATIONS STATEMENT - LICENSEE

1. APPUCANTS #UL4 NAM 4 IWur, stepnsses 4. TYPE Of APPuCATIOes t~r ammeses messes i.not .. AsAPPUCATiON t WArveR ReOussTio l l (,AssFy mi sowrees A00RS65 OR RPO NUM64R 3-COLO 1-PiR$7 s.warrim ec Roww

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2. CITLithsMIP 3 8'ATM OAft 6. MQLT14/Nf7

a. UNiito STAfts

k. OTHER #8eseM l j j S TYPE OF UCENSE APPUID POR 4. PREvtOUS UCENSatS6 HELO

s. RA OR a. OOCKET NUMsER yy D. UCENSE NuwsER g D* ATjfh CA'E d FAQUTY OOCKf7 NUMeta 8 SENIOR OPERATOR 56 4 UMITED $RO fe p. #wsf NatRyf i i i F NAME OF APPUCANTS EMPLOYER 10. CURRENT POSITION AT FACIUTY a PLANT $UPERINTENCENT L AUXauARY UNff OPERATOR /

ADORESS b. ASSISTANT PLANT SUPERINTENDENT pg, 'o A

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c SHIFT SUPERvtSOR

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OTY TATE ZIP CODE d STAFF ENGINEER pg, ,.

e $MFT TECHMCAL AOvi$0R/$wFT ENGNEER 8 NAME OF APPUCANTS FACiUTY l FAOUTV DOCKET f INSTRUCTOR l NUMBER

g. SEMOR CONTROL ROOM

3. ADOiiiONAL F AQUTV DOCKET $ (MuRe Umr Lcenses, OPERATOR h CONTROL ROOM OPERATOR

11. COUCATION a Dr *1 $La*00L g. MAJOR AREAt$1 OF STUOY ON'a',"s NrMT l 0 GA CO I ,,uese d. VOCATiONAUTECHMCAL o,"%AHS CA9E FC D GRAOUATE ENGNEER'hG 8'88 * * * * * *

• aoramed J TYPE OF TRAtNtNG YES NO GEO EQUtvALENCY 0- NONE OfstR t - CE R TIF8 CAT E No

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b NUMBER OF YEAR $

OF COLLEGE 3- S ACHELOR 4 - M A STER 5-DOCTOR AL i

12. TRAANissG 13. EXPERIENCE l

b NUMBER a. MONTH ANO YEAR b NUMBER le MONTH l soeu l 70AND I YE.ARlOF I WEEKS l sacM TO i-NUCLEAR POWER PLANT FUNDAMENTALS I [ l I NAVY fOsesreum# l { l l t p0 2-PLANT SYSTEMS 2 - EOOW / PPWO CLASSROOM l l 3 - EWS / PPWS OS$ERVATION l l l l 4-ERSs CRW l

3-OPERATING PRACTICE 5-OTHER isoseAs l l CONTROL ROOM OPE 11AT10NS ON SHIFT l l t. ,

SIMULATOR OPERATING #fncfwsse Classroosn, 6-OPERATOR l

SIMULATOR NAMEt51 7-SUPERvtSOR h 8-PLANT STAFF a VES NO 3-OTHER (SoecWP

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.- COMM,ERCIAL Roe, NUCLEAR flacsudng Rosen*/ Test

! 10 REACTOR OPERATOR rLes==ssas

. - sRO WsTRUCriON l u- sEMOR OPER AToR an e.,,

.-ExTRAPEasos;ON .,T l l l iss-FT supervisor a- ,

6 REQUAUFtCATION l l l 13-STAFF.$HtFT ENGNEER (troneedi 7-0TwERes <*, l l i4- Aux , EOU.P <NONuCE=sEO, OPER ArOR

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! 14 FacauTY OPERATOR TRAINsNG PROGR AM a GRADUAft OF sNPO ACCREDIIED OPERATOR b. CERTIFIED ON NRC Form 474 t SIMULATION F AC1UTV CERTin TRasNeNG PROGRAM ATION"i OR NRC APPROVEO SrMULATON F AOUTY 13 USED IN THE OPERATOR TR AsMNG PROGRAM lvES l lNO lYES l lNO il FOR RENEWALS ONLY HOURS OPERATEO FACluTY:

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16. EXPEnatNCE DETAILS ,

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17. C0eseeS8Ef5 (Seespir sne men numeer se anun peu as aseeemps t1 NetC postes 318. CERTtPICAftOes Os eseDeCAL emmefeATIOss gY FACM.ffY UCasesEE IS ATTACNED.

Any fases sneemment or ommason en the -- metuding attacsiment4may be suegoct to cswe and enmmal senccons.

19e. I coefy isness oeruey of sornsrv shot sie ederinesen m sie escismene and anschmene e eue and conect. I see authorse the NRC es eutwn4 the resuste et enemsnenene se my emonevere for une e ereseng

'e898486 88eW488u. 8e nesseeWy I

SIGNATunt- APPUCANT I OATE D. I eere8v that the anewa named _ ^ has - - --comessess the feuhty heereses recuremense to the beensed as an OmeretortSensor Opereser eurmserit to Tiene 10. Como et Feenre Regumesons. Port 56:

and stat see aussensal hee e nees for an Osameer#5ew Osorseer empus se seterm hather ausseres asusse and that the tecday assi ne shade evodesse for examaneten. I snee eartdy unsser .senemy of seriury that the edensumen a the assunurut one aneshmenes e eue one cermet.

. I SIGNATUAE-TRAssessG COOAOsNATOR 3 OATE $iGNATunE-$ENeQR MANAGEMENT #EP8ESENTATIVE ON &lTE 8 OATE

s. IIG80EWAL 08e4Y. I esefy shot she seawe comes eiewedusi museus se soorowse veossercamen program tensen e nmee a sen f 77 as resures ey escnon 50 to EMI et to CFR 50. ene ehet sehe hee es-cresged hatter scenese _ cessgenomey one seessy. I ene cendy under senemy et earnay that the adormetson en the document and anschmente e eue end cervect.

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f siGNarumE-TnAscNG COOaOeNATOm 3 OATE siGNArumE-SEN#0m MANAGEMENT REPRESENTAftvt ON $1TE l OATE i FOR NRC USE w A'via ,oisce e, e.ne men. as -* MEETS REQUtAEMENTS I, """'

GaaNTED ev Ofael0 e' MES W MEET REOuipfMENTS I

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ENCLOSURE 2 f

SUMMARY

OF CHANGES TO NRC FORM 398 Item 4.a - Moved "New" to below " Hot" and " Cold". '

Item 4.f - Combined " Oral" an'd " Simulator"'into " Operating". -

Item 5.d - Deleted " Instructor Certification".

Iten 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 Form 396, Certification of Medical Examination by Facility Licensee is attached" to indicate that in order for the application to be complete the NRC Fom must be attached.

Statement Added - Any false statement or omissions in this document including attachments, may be subject to civil and criminal sanctions.

Item 19.a - Changed the wording to read ". . . certify under penalty of perjury that the infomation in this document and attachments is true and correct. I also . . ."

Item 19.b - Changed the wording to read ". . . has ,

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

, infomation in this document and attachments is true l and correct." Changed signature block from

" Highest Level Of Corporate Management for Plant Operation" to " Senior Management Representative On Site."

l Item 19.c - Added the wording "I also certify under penalty of perjury that the information in this document and attachments is true and correct. Changed signature block from " Highest Level of Corporate Management for Plant Operation" to " Senior Management i

Representative On Site."

I t- FOR NRC USE - Under waiver category combined " Oral" and l " Simulator" into " Operating".

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ENCLOSURE 3 jr -

e 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).

A SEPARATE NRC FORM 398 FORM MUST BE SUBMITTED EACH TIME AN APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.

ITEM 1 -

FULL NAME AND CURRENT ADDRESS.

ITEM 2 -

CITIZENSHIP. If other than U. S. Citizen, citizenship must be specified.

ITEM 3 -

DATE OF BIRTH.

, ITEM 4 -

. TYPE OF APPLICATION.

l "X" applicable 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 application.

s. New - Applying for the first time at this facility OR 11 previously applied for a license but withdrew (write in "previously withdrew" next j

to New). ALL ITEMS MUST BE l- COMPLETED ON A NEW APPLICATION l AND SHOULD INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE RECEIVED j

UP TO THE DATE OF THIS APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

I

'" --e - , . , - , , _ - , , , _ , _ _ , _ __ __ _

- 2 p

b. Renewal - Now holds a license and is renewing that same type of license. 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.

c. Upgrade - Now holds an operator's license and is applying for a senior operator's license.

ALL ITEMS MUST BE COMPLETED ON-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.

d. Multi-unit - Applying for a license on more than one unit OR is a licensed operator on l

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 APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST

, APPLICATION.

THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

e. Reappilcation - Previously took a licensing 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.

a 1-First - If de.iied a license for the first time, the appilcant must wait two months from the date of denial letter before reapplying for a license.

2-Second - If denied a license for the second time, tha 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 waiver 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 walver on an operating exam.

3-Eligibility - To request a waiver on eligibility requirements.

4-Other - To request any other walver, i.e., medical.

ITEM 5 -

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).

l I

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 (55-XXXXX). Indicate if this license was for RO or SRO. If this was for

Instructor Cortificotton or Lloited Senior Operator, please write in.

If a dental letter was issued, a docket number was assigned and should be Indicated in this block.

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 license expiration.

If several renewals have occurred, list only latest expiration date.

d. Facility Docket No. -

Docket number of facility where appilcant 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.

ITEM 7 -

NAME OF APPLICANT'S EMPLOYER llame and address of current employer.

ITEM 8 -

NAME OF APPLICANT'S FACILITY Name and docket number (50-XXX) of facility where applying for a license.

ITEM 9 -

ADDITIONAL FACILITY DOCKETS If applying for multi-unit i

license ALL applicable additional docket numbers must be entered.

1 ITEM 10 -

CURRENT POSITION AT FACILITY

, s. Plant Superintendent -

Note license type if required

( by position.

b. Assistant Plant Superintendent -

Note license type if required by position.

r

c. Shift Supervisor -

Position requires current senior license for a plant i with fuel in the reactor.

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d. Staff Engineer -

Note license type 11 required by position.

, e. Shift Technical l Advisor / Shift Engineer- Note license type if required j by position.

l f. Instructor -

Note license typa if required by position.

l I

g. Senior Control Room 6 Operator - Position requires current senior license for a plant with fuel in the reactor.

h. Control Room Operator - Posit' ion requires current operator license for a plant with fuel in reactor.

l. Auxiliary 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 Junior = 2 to 3 years Senior = 3 to 4 years Graduate = 4 years or more)

c. Major Area (s) of Study-Engineering - Fleid of engineering majored ins number of years, ands highest degree obtained.

Other - Other field majored ins number of years, ands highest degree obtained.

d. Vocational / Technical -

Type of Training- Vocational / technical training schools, including allitary schools, applicable to the operation of a l

pcwor plcnt. Includo such programs as nuclear power school,

(

air conditioning / refrigeration school, diesel mechanic school, instrumentation and control maintenance, etc.

Number of Months- Calculate the approximate number of full months appilcant received I 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 cer^ificate 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-Huclear 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.

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3-Operating Practico - Training in oporating practicos in tne control room for which the

- candidate will license and at a plant referenced simulator if one is evallable.

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 4

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 Completed -

"X" Yes or No. (Notes For facilities with plant referenced simulators, certification of 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.)

i Number of Reactivity Manipulations: - Number of actual reactivity manipulations in which the applicant was involved broken down by plant and simulator. (Detafis should be provided in Comments, Item 17.)

4-SRO Instruction -

Instruction in the duties of a senior operator.

-B-

/ 5-Extra Person on Shift - Must be a minimum of three months l .

on shift performing the actual duties of the licensed position applied for. These duties are performed under the direct supervision of Ilconsed 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 enough to allow evaluation.

Include number of research reactor startups, if performed.

ITEM 13 -

EXPERIENCE - Experience is indicated in months.

For each position helo, list the month / year to cover the period you were quallfled 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 amount of time assigned to those particular duties. In no case should the number of months reported for a particular time period exceed the number of months that are in that time period. Also, do not count time in training.

NAVY -

Military nuclear power experience should be listed in 1-5.

Non-nuclear military power experience should be listed under Fossil 6-9.

1-RO - Quallfled to operate the controls of a Navy Propulsion or training reactor.

2-E00W/PPWO - Authorized to supervise the operation of Navy Propulsion plants.

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1 a) Graduate of INPD Accredited Operator s Training Program "X" Yes or No 11 the applicant is a graduate of an INPO accredited operator training program. (NOTE:

INPD accredited means accreditation by the National Nuclear Accrediting Board.)

I b) Certified on NRC Form 474 1 (Simulation Facility Certification) ,

or NRC Approved Simulation Facility i is Used in the Operator Training Program "X" Yes or No 11, in the operator training program, a certified on NRC Form 474 or NRC approved simu?ation 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 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 items on the application form. If space provided is not sufficient, extra pages may be attached to application.

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ITEM 18 - NRC FORM 396, CERTIFICATION j OF MEDICAL EXAMINATION BY i FACILITY LICENSEE - Any application for a license or renewal of Ilconse 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 if the original medical i

evaluation was performed within I one year. If walver is requested, Item 4.f.4 should be marked.

3-EWS/PPWS -

Quellfled to direct and supervise the operations of a Navy Propulsion plant.

4-ERS/CRW -

Quellfied 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 propulsion / power plant operation.

7-Supervisor -

Authorized to direct and supervise non-nuclear operstors.

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 4 senior operator license.

12-Shift Supervisor (Licensed) -

Must hold or have held valid NRC senior operator license.

4 13-Staff / Shift Engineer (Licensed) -

Must be at the facility and involved in the day-to-day 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.

16-Other (Specify) -

Ensure description is detailed l enough to allow evaluation.

ITEM 14 -

FACILITY OPERATOR TRAINING PROGRAM If "Yes" is checked in BOTH a) and b) then Items 11 (Education),

12 (Training), 13 (Experience), and 16 (Experience Details) DO NOT

have to be completedi except new applications must still include the number of significant control manipulations under Item 12.3.

ITEM 19 - SIGNATURES REQUIRED l Any falso statement or ommission in this document, including attachments, any be subject to civil and criminal sanc,tions.

o. 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 appilcant has successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant to 10CFR551 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(1-1) of 10CFR50 and has discharged licensed responsibilities competently and safely.

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