ML20214S742

Forwards Revised NRC Form-398, Personal Qualifications Statement - Licensee. New Applicants Required to Complete Each Category Completely,Including All Education,Training & Experience Received Up to Date of Application

ML20214S742
Person / Time
Site:	Ginna
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Kober R ROCHESTER GAS & ELECTRIC CORP.
References
NUDOCS 8706090394
Download: ML20214S742 (17)

Text

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JUN 4 1987 Docket No. 50-244 Rochester Gas and Electric Corporation ATTN: Mr. Roger W. Kober Vice President Electric and Steam Production 49 East Avenue Rochester, New York 14649 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 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. is a set of instruc-tions for the completion of all items on the NRC Form 398.

All application:: 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.

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8 OFFICIAL RECORD COPY OL MULTI'LTR - 0029.0.0 l

8706090394 870604 PDR ADOCK 05000244-V PDR

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.g Rochester Gas and Electric Corporation 2

If you have any questions regarding this form. please contact Robert M. Keller at 215-337-5211.

Sincerely, e.-!5innl Signed Bysf Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

R. Marchionda, Training Manager Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector cc w/o enclosures:

Central Records (4 copies)

State of New York (w/ enclosures)

Harry H. Voigt Esquire bec w/ enclosure,s:

OL Plant File Examiners RI:

RI D P P

Lan mjd/gcb Ke s

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87 6/2//87 6/.S/87 0FFICIAL RECORD COPY OL MULTI LTR - 0030.0.0 05/29/87

INSTRUCTIONS FOR COMPLETING NRC FORM 338, PERSONAL QUALIFICATIONS STATEMENT-LICENSEE NEW APPLICANTS. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE INSTR ALL EDUCATION. TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS AP RENEWAL UPGRADED. MULTI. UNIT, AND REAPPUCATION APPLICANTS. COMPLETE EACH CATEGORY OF FORM COMPLETELY INO8CATE ONLY THE EDUCATION. TRAINING. AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST SPECIFIC INSTRUCTIONS FOR ITEMS 1113:

INDICATE BOTH ACACEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION F0 11 -E DUCATION:

COOE INOICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE PROVIDEO. FOR VOCATIONAL / TECHNICAL EDUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR PO CONDITIONING /REFRIGER ATION OIESEL MECHANfC $CHOOL. ETC. INDICATE THE NUMBER OF MONT A CERTIFICATE OR OEGREE WAS AWAROED iF ADOIT60NAL $ PACE IS NEEDED. CONTINUE UNOFR ITEM 17 12-TRAINtNG. iN THIS ITEM INOICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMEN BREAKOOWN OF TR AINING IN THIS CATEGORY P ARALLELS THE ANS STANDARDS: PLEASE REFER T CLARIFICATION. INCLUCE SOTH BEGINNING ANO COMPT.ETION DATES AND THE TOTAL NUM8ER OF WEEK ING. NUMBER OF WEEKS IS PROVIOEO. IN ADDITION TO SEGINNING AND COMPLETION DATES. TO ACC IFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERIOOI. THEREF OfCATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENTIN FULL-nME TRAINING. T APPUED FOR CANNOT BE OOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.

ALL RECUALIFICATION TR AINING TIME IS TO BE ACCOUNTED FOR IN THE REQUAUFICATION ITEM. PLEASE AV ING ALL THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUAltflCATION. EVEN THOUGH (T MAY INCLUDE CLASSR OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH POSITION HELO. COMPLETE ITEM 16. 00 NOT OOUBLE COUNT TIVE. IF YOU HAO OVERLAPPING OUTIES, THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICUL THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIGO EXCEED THE NUMBER OF MONTHS TH AT

e. GRAOUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM: ANDD. CER-14-FACILITY OPERATOR TRAINING PROGR AM. INDICATE TIFIEC !CN NRC FORM 474) OR NRC APPROVED SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGR A IN BOTH ITEMS e ANO b, THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCE. AND 16 FYPCRIFNCF OCTAILS fiO NOT HaVE TO BE COMPLETEC; [1;(PT G MMCMIC:G %$7 371LL IHaOCE inE MSCR OF $!CMIFICANT CONTROL fWi!PULATIONS UNU(R II(M 12.3.

NOTE: INPO ACCREDITED MEANS ACCRE0lTATION SY THE NATIONAL NUCLEAR ACCREDITING BOARD.

15-FOR RENEWALS ONLY: ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF UC A EN EWAL 16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERICO FROM/TO,FACluTY. AND A 8R;EF DESCRIPTION OF DUTIES PERFORMED wwiLE SERVING IN TH AT POSITION. IF MORE SPACE l$ NEEDED USE ITEM 17. OR IF NECESSARY ATTACH ACOITIONAL 4NFORMATION 17-COMMENTS: USE THl$ SP ACE TO INCLUCE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPUCA IF THE SPACE PROVIDED 15 NOT SUFFICENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION BY FACluTY UCENSEE. MUST ACCOMPANY THIS APPUCATION.

19-SIGNATURES: SIGN AND OATE ITEM 19.e. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGE VENT REPRESENTATIVE ON SITE.

OETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 396. IN TRIPUCATE (ongsnel and rm cooes) ANO 396 TO THE APPROPRI ATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. 552ef el(31. enacted into law by Section 3 of the Pnvecy Act of 1974 (Public Law S3-5751. the following is furnished to in-dividuele who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. This information is maintained in e system of recorde designated as NRC 16 and desenbod at e6 Federal Register 46717 (September 21. 1981).

1. AUTHORITY. Section 107 and 161(l) of the Atomic Energy Act of 1964. as amended (42 U.S.C. 2137 and 2201 till.

2. PRINCIP AL PU RPOSES. The informenon will be collected and evaluated for determining licenomg eligibility and to generate statistical date and reports on licensing actions.

3 ROUTINE USES. Information entered on this form may be used to: (el determine if the individuet meets the requirements of 10 CFR Part i

55 to be issued en operator's license: (b) provide resseechere with information for statistical evolustions rotated to selection, treamng, and esommetson of f scierty operators: (c) provide f acietty menegement with sufficient inf ormation to oneoil the individuals in the licensed operetot ter,uelification progrem; (d) provide for enemination and testing metenal and obtain resulte from contractors.

4. WHETHER DISCLOSURE l$ M AND ATORY OR VOLUNTARY AND EFFECT ON IN0ivlDUAL OF NOT PROVIDING INFORM ATION: Disefoeure is voluntary. However. if the information requested is not provided. NRC edl not be obte to evoluete whether the application meets the requirements of 10 CFR Part S6.

5. SYSTEMS MANAGERS AND A00RESSES.

Regiones Admannstrator. Region I Regional Administrator, Reg.on if U S. Nuclear Reguastory Commess.on U.S. Nveteer Regulatory Commrssion 631 Part Avenue 101 Merwete Street. Suite 2900 Kag of Pruss.e PA 19406 Attente. GA 30323 Regioned Administrator Region ill Reg.onee Admnstrator. Region IV Regiones Adm mstrator. Region V U S. Nucwer Regutatorv Comm,ss.on U.S. Nuossi Requietory Commrssson U.S. Nucieer Regulatory Commess.on 799 Rooseveit Road 611 Ryan Plate Orsve. Sveie 10(X) 1450 Marie Lane. Suete 210 G6en Wn. il 60137 Art.ngtori. TX 76011 Weinut Creet CA 94596

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'A N#C PonM M CERTIrtCAftces OF MEOeCAL EXAMsetATION SY FACluTY UCENSEE IS ATTACHEO.

Any falso statement or Ommeen et the cocumervt, includeng attachmentsLmay be suOsect to cmi and Cnminal sanctione 1se. t cerW, vaser sonen, es earwrv est se mearmaman a vie secwnent ens enschmans a sue one correct. t ano autnorme se NnC es mdenu the renuns et ensemetens so my emoevers ser use a preoereig mvemg progrene, as neseauery 1

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ENCLOSURE 2

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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 Deleted " Instructor Certification".

Item 5.d Added a new item " Facility Operator Training Itera 14 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.

Added a new item "For Renewals Only. Hours Operated Item 15 Facility". (This was origina11y'under Experience).

Renumbered previous items 14 through 17 to 16 Items 16 through 19 through 19.

Changed to read "NRC Form 396, Certification of Item 18 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 information 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 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 Representative On Site."

Added the wording "I also certify under penalty Item 19.c 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 Representative On Site."

Under waiver category combined " Oral" and FOR NRC USE

" Simulator" into " Operating".

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ENCLOSURE 3 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.

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 licensa at a plant that has not achieved initial criticality. This should be completed for each appilcation.

a.

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 i

UP TO THE DATE OF THIS APPLICATION.

l THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

1 l

2 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 j

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

]

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.

1 e.

Reapp11 cation "reviously took a licensing exsia sad was denied a license and !s now reapplying for i

that same type of IIcense at the same facility.

The reappilcation should identify those areas in which the appilcant demonstrated weaknesses during the previous examination i

and the additional training received to correct these i

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.

j i

i

3 i

If denied a license for the 1-First l

first time, the appilcant J

~

must wait two months from the date of denial letter before reapplying for a license.

If denied a license for 2-Second the second time, the appilcant must wait six months from the date of denial letter before reapplying for a license.

If denied a license for 3-Third the third time, the appilcant 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 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 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).

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

-4~

Instructor Cortificotton or Lioltod Senior Operator, please write in.

If a denial 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).

Date of Ilconse expiration.

c. Expiration Date If several renewals have occurred, Inst 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 Name and address of current employer.

NAME OF APPLICANT'S FACILITY ITEM 8

- Name and docket number (50-XXX) of facility where applying for a license.

ADDITIONAL FACILITY DOCKETS ITEM 9 If applying for multi-unit license ALL appilcable additional docket numbers must be entered.

ITEM 10 CURRENT POSITION AT FACILITY Note license type if required

a. Plant Superintendent by positinn.

b.

Assistant Plant Note license type if required Superintendent by position.

Position requires current

c. Shift Supervisor senior license for a plant with fuel in the reactor.

Note license type if required d.

Staff Engineer by position.

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

Note license typa if required f.

Instructor by position.

9 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. 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 Junicr= 2 to 3 years Senior = 3 to 4 years Graduate = 4 years or more)

c. Major Ares (s) of Study-Engineering

- Field of engineering majored ini number of years, and; highest degree obtained.

Other

- Other field majored in; 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

power plant.

Include such programs as nuclear power school, air conditioning / refrigeration school, diesel mechanic school, instrumentation and l

controi maintenance, etc.

f I

Number of Months-Calculate the approximate number of full months applicant 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 l

Received

- Indicate if certificate was received for this training.

TRAINING

- Training is indicated in weeks ITEM 12 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 i

the theory of the nuclear fission J

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 l

equipment.

i

Training in operating practices 3-Operating Practice In the control room for which the candidate ulll license and at a plant referenced simulator if one is evallable.

j l

Control Room Observation of the operating j

Operations 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 Practice in manipulating plant (Includes Classroom) controls during normal, abnormal and emergency conditions on a plant referenced simulator.

Specify the simulator (s) where Simulator Name(s) training was received.

If more than two simuistors specify the two most recent only.

Startup Certification "X" Yes or No.

(Notes For Completed facilities with plant referenced simulators, certification of startup training will be provided by the facility organization.

For those i

I facilities without a plant referenced simulator, startup certification must 1

be obtained from the organization at which the startup demonstration was performed.)

Number of Reactivity Manipulations:

- Number of actual reactivity manipulations in which the appilcant was involved broken down by plant and simulator.

(Details should be provided in Comments, Item 17.)

4-SRO Instruction

- Instruction in the duties of 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 Ilconsed personnel on normal shift rotation.

This should be I

In a structured, documented program.

j Do not double count this time in 12.3 or as operating experience.

ALL requalifications training, 6-Requalification including classroom and simulator time.

Ensure description is detailed 7-Other (Specify) enough to allow evaluation.

i Include number of research reactor startups, if performed.

Experience is indicated in months.

EXPERIENCE ITEM 13 For each position held, ilst 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-1 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 i

time period exceed the number of months that are in that time period.

Also, do not count time i

in training.

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

NAVY I

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

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

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

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10 a) Graduate of INPD Accredited Operator Training Program "X" Yes or No if the appilcant 15 a graduate of an INPD accredited operator training program.

(NOTE:

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

b) Certified on NRC Form 474 (Simulation Facility Certification) or NRC Approved Simulation Facility 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 simulation facility is used.

1 ITEM 15 -

FOR RENEWALS ONLY - NOURS OPERATED FACILITY:

- The approximate number of hours applicant 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 1

items on the application form.

If 4

space provided is not sufficient, extra pages may be attached to 4

appilcation.

ITEM 18

- NRC FORM 396, CERTIFICATION OF MEDICAL EXAHINATION BY F ACILITY LICENSEE'

- Any appilcation for a license

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I or renewal of Ilcense is not complete without NRC Form 396.

A medical is good for six months from the date the physician signs i

it.

For appilcations following a l

voluntary withdrawal or license denial or an upgrade application, waivers may be granted on a case basis if the original medical evaluation was performed within one year.

If walver is requested, Item 4.f.4 should be marked.

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, l 3-EWS/PPWS Quellfled to direct and supervise the i

operations of a Navy Propulsion plant.

i 4-ERS/CRW Quellfled to direct and supervise Navy Propulsion plant operations outside the maneuvering area.

5-OTHER (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 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.

12-Shift Supervisor (Licensed)

Must hold or have held valid NRC senior operator license.

13-Staff / Shift Engineer j

(Licensed)

Must be at the facility and j

involved in the day-to-day i

plant operational (engineering) staff work.

14-Aux./ Equip. (Nonlicensed)

Operator Personnel used in direct support 1

of plant operations as directed by Ilconsed operators.

15-Plant Staff Staff work other than that directly associated with plant operations.

16-Other (Specify)

Ensure description is detailed i

enough to allow evaluation.

FACILITY OPERATOR TRAINING PROGRAM ITEM 14 If "Yes" is checked in BOTH a) and b) then Items 11 (Education),

2 12 (Training), 13 (Experience), and 16 (Experience Detalls) DO NOT have to be completodi except new applications must still include the number of significant control manipulations under Item 12.3.

ITEM 19

- SIGNATURES REQUIRED Any false statement or ommission in this document, including attachments, any be subject to civil and criminal sanctions.

o. Date and signature of applicant 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 ul11 be evallable for examinations.

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c. RENEWAL ONLY - Must be signed and dated by Training Coordinator AND Senior Management Representative On Site certifying, under penalty of perjury, that applicant meets the approved requalification program i

(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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