ML20214S770

Forwards Revised NRC Form 398, Personal Qualifications Statement - Licensee for All Applicants for Licenses to Complete,Per 870526 Rev to 10CFR55.Graduates from INPO & Approved Simulation Facility Need Not Complete Form

ML20214S770
Person / Time
Site:	FitzPatrick
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Radford Converse POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
References
NUDOCS 8706090410
Download: ML20214S770 (17)

Text

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JUN$E 1987 Docket No. 50-333 Power Authority of the State of New York James A. FitzPatrick Nuclear Power Plant ATTN: Mr. Radford J. Converse Resident Manager P. O. Box 41 Lycoming, New York 13093 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 educsLion, 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 submicted 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.

O gg $8 3

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?y 0FFICIAL RECORD COPY OL MULTI LTR - 0017.0.0 05/29/87

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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, OeigiN1SIAned117/

Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

D.'Simpson, Training Coordinator Public Document Room (PDR)

Local Public Document Room (LPDR)

' Nuclear Safety Information Center (NSIC)

NRC Resident Inspector cc w/o enclosures:

L. W. Sinclair, President J. P. Bayne, First Executive Vice President and Chief Operations Officer A. Klausmann, Vice President - Quality Assurance and Reliability R. L. Patch, Quality Assurance Superintendent George M. Wilverding, Chairman, Safety P.eview Committee NRC Licensing Project Manager Dept. of Public Service, State of New York StateofNewYork~(w/ enclosures)

Gerald'C Goldstein, Assistant General Counsel bec w/ enc.losures:

OL Plant File Examiners RI:D RI tRP P

Lan jd/geb Ke1 Ilins b/t/87 8/*/87 6/ 3 /87 0FFICIAL RECORD COPY OL MULTI LTR - 0017.1.0 05/29/87

t-INSTRUCTIONS FOR COMPLETING

,NRC FORM 338. PERSONAL QUALIFICATIONS STATEMENT-LICENSEE o

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.

RENEWAL. 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 item 14.

SPECIFIC INSTRUCTIONS FOR ITEMS 1119:

11-EDUCATION: INDICATE BOTH ACADEMIC AND VOCATIONAUTECHNICAL 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.

12-TR AINING: IN THIS ITEM INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REOUtREMENTS OF ANSI N18.1/ANS 3.1. THE 8REAKDUWN OF TRAINING IN THIS CATEGORY P ARALLELS THE ANS STANDARDS: PLEASE REFER TO THE STANDARDS IF YOU NEED FURTHER CLARIFICATION. INCLUDE 80TH BEGiNNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAIN-ING. NUMBER 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 PERIODI. 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.

ALL RECUAUFICATION 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.

13-EXPERIENCE: FOR EACH POSITION HELD. COMPLETE ITEM 16. 00 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. 6NDICATE

a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM: AND b.CER.

TIFIED (ON NRC FORM 4746 OR NRC APPRCvED SIMULATION FAC1UTY IS USED IN THE OPERATOR TRAINING PROGRAM. IF YES IS CHECKED IN BOTH ITEMS a AND b. THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCE. AND 16 FXpFRIFNCE OFTAILS 00 NOT HaVE TO BE COMPLETED; ExCEPT NEW APRICATICH3 K,ST 3T!it thCLUCI THE NUMBER OF SIGNIFICAMT CONTRML MMIPULATIONS UNDER ITEM 12.3.

NOTE: INPO ACCREDITED 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 RENEWAL.

16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERIOD FROM/TO,FACIUTY. AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEEDED. USE ITEM 17. OR IF NECESSARY ATTACH ADOITIONAL INFORMATION.

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.

18-NRC FORM 396. CERTIF1 CAT 10N OF MLDICAL EXAMINATION SY FACluTY UCENSEE. MUST ACCOMPANY THIS APPUCATION.

19-SIGNATURES: SIGN AND DATE ITEM 19a. 08TAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGE.

MENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398. IN TRIPUCATE (onganat and two coosesJ AND 396 TO THE APPROPRIATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. 562steH3L enacted into law by Section 3 of the Pnvecy Act of 1974 (Public Law S3-5791, the following is furnished to in-dividuals who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. This information is maintemed in a system tf recorde designated as NRC 18 and de4cnbod at 46 Federal Register 46717 (September 21,19811.

1. AUTHORITY. Section 107 and 181(1) of the Atomic Energy Act of 1964. as amended (42 U.S.C. 2137 and 2201 (ill.

2. PRINCIPAL PURPOSES. The informanon will be codec ed and evaluated f or detecmining licensing eligibility and to generate statistical data and reports on licensmg actions.

3. ROUTINE USES. Information entered on this form may be used to: fal determine if the individual meets the requiremente of 10 CFR Part 55 to be issued an operator's license: (bl provide researchers with infor...ation for statistical evaluations related to selection. traming, and examination of f ac Irty operetore: (c) provide f acility menagement with sufficient information to entoil the individuals in the licensed operator regaalification program; (d) provide for esaminetton and testing metenal and obtain results from contractors.

4. WHETHER DISCLOSURE IS MAND ATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORM ATION: Disclosure is voluntary. However, if the information requested is nn provided. NRC will not be able to evaluate whether the application meets the roovirements of 10 CFR Part 55.

5. SYSTEMS MANAGERS AND ADDRESSES:

Regional Adminestrator Region i Regionsi Admenistrator. Region 11 U S. Nuclear Regulatory Commessaon U.S. Nuclear Regulatory Commission 631 Part Avenue 101 Marietta Street. Suete 2900 King of Prusst PA 19406 Atlanta GA 3G323 Regonal Adminrstrator. Region ill Regionae Adminestrator. Region IV Regiow Admenestrator. Region V RS. Nucsear Reguiatory Commrssion U.S. Nucheer Regulatory Commrssion U S. Nuclear Regulatory Commiss on 799 Rooseveit Road 611 Ryan Ptaza Onve. Suite 100C 1450 Maria Lane. Suite 210 Glen Ellvn. IL 60137 Artington. TX 76011 Wainut Creen. CA 94596

N POAM 388 U. S. NUCLEAR REGULATORY COMMISSION

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- ENCLOSURE 2 g-SUMARY 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".

Item 14 Added a new item " Facility Operator Training Program" and incorporated under this item the INP0 accreditation block (originally under Training);

added a block for NRC approved or NRC Form 474 certified simulation facility.

l l

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 Form 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 information 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 and correct." Changed signature block from

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

Item 19.c Added the wording "I also certify under penalty of perjury that the 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."

FOR NRC USE Under waiver category combined " Oral" and

" Simulator" into " Operating".

ENCLOSURE 3

)

PERSONAL QUALIFICATIONS STATEMENT - LICENSEE NRC FORM 398 CREV 4/87) l NEW APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 COMFLETELY, FOLLOWING INSTRUCTIONS BELOW.

THIS IS TO INCLUDE ALL EDUCATION, TRAINING, AND EXPERIENCE THAT APPLICANT NAS 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 SUEMITTED EACH TIME AN APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.

FULL NAME AND CURRENT ADDRESS.

ITEM 1 f

ITEM 2 CITIZENSHIP.

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

DATE OF BIRTH.

ITEM 3 TYPE OF APPLICATION.

ITEM 4 "X" applicable boxes:

1-Hot

- Applying for a license at j

.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 compiated 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 UP TO THE DATE OF THIS APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

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 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.

.l.

THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

e. Reapp11 cation

- Previously took a licensing 1

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 l

specific deficiencies in Item 12.7 and/or Item 17.

ALL 4

l 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.

.3-1-First

- If denied 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, the appilcant must wait six months from the date of denial letter before l

reapplying for a license.

3-Third

- If denied a license for the third time, the applicant must wait two years from the date of dental letter before reapplying for a license.

f. Walver Request

- NOTE:

Justification for any J

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 walver on an operating exam.

3-Eligibility

- To request a waiver on eligibility requirements.

4-Other

- To request any other waiver, i.e.,

medical.

TYPE OF LICENSE APPLIED FOR ITEM 5

a. Operator

- Applying for an operator license.

b.

Senior Operator

- Applying for a senior operator license.

c. Limited SRO

- Applying for a ilmited senior operator license (e.g. fuel handler).

PREVIOUS LICENSE (S) HELD ITEM &

- To be completed if previously i

held a license (or Instructor certificate).

a.

Docket Number

- Docket number assigned for previous license (s) held l

(55-XXXXX).

Indicate 11 this license was for RO or SRO.

If this was for

Instructor Cortificotion er Lloitod 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 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.

ITEM 7 NAME OF APPLICANT'S EMPLOYER Name 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 Ilconse ALL applicable 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 l

Superintendent Note license type if required i

by position.

c. Shift Supervisor Position requires current senior license for a plant with fuel in the reactor, d.

Staff Engineer Note license type 11 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 - Pcsit' ion requires current operator license for a plant with fuel in reactor.

1. Auxillary Unit Operator / Trainee /

Turbine Building /

Equipment Operator (non-licensed operator)- Ensure description is detailed enough to sllow 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 Graduates 4 years or more) l

c. Major Area (s) of Study-Engineering

- Fleid of engineering majored Int number of years, ands highest degree obtained.

Other

- Other fleid majored Int 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

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 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.

I ITEM 12 TRAINING

- Training is Indicated in useks 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 treining spread over a two month period).

Therefore, the date column may indicate a Isrger 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 as1 functions.

Observation

- Planned systematic observation training on accessible plant equipment.

s 3-Operating Practice

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

Controf Room Operations Observation of the operating practices and the operation of nuclear power plant from the central control room.

Not license candidates must manipulate the controls under direct supervision of a licensed operator at the individual's duty station for a verlety of plant operations.

Cold license candidates are to participate in the plant l

preoperational testing program.

Actual time assigned to the operating shift should be counted in 12.5 below.

4 l

Simulator. Operations (Includes Classroom)

- Practice in manipuisting 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 l

than two simulators specify j

the two most recent only.

1 Startup Certification Completed "X" Yes or No.

CNotes For t

facilities with plant referenced simuistors, certification of startup training will be provided by the facility organization...For those facilities without a plant referenced i

simulator, startup certification must be obtained from the organization at i

{

which the startup demonstration was

{

performed.)

Number of Reactivity Manipulations:

- Number of actual reactivity

,i manipulations in which the appilcant was involved broken down by plant end simulator.

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

4-SRO Instruction

- Instruction in the duties of a senior operator.

I

?

-B-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 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 simuistor time.

7-Other (Specify)

- Ensure description is detailed enough to allow evaluation.

Include number of research reactor startups, if performed.

EXPERIENCE

- Experience is indicated in months.

ITEM 13 For each position held, ilst 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.

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

l NAVY Non-nuclear allitary power experience should be listed under Fossil 6-9.

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

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

_.____,_____,__J

.g.

3-EWS/PPWS Quellfled 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 detalled 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.

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 plant operational (engineering) staff work.

14-Aux./ Equip. (Nonlleentod)

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 enough to allow evaluation.

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

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.

I l

a) Graduate of INPO Accredited Operator Training Program "X" Yes or No if the applicant is a graduate of an INPD accredited operator training program.

(NOTE:

INPD accredited means accreditation i

by the National Nuclear Accrediting i

Board.)

b) Certlfled on NRC Form 474 (Simulation Facility Certification) 1 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 should be used if more space is needed.

t l

ITEM 17

- COMMENTS

- This space should be used to complete information from previous Items or clarification for other Items on the application form.

If l

space provided is not sufficient, extra pages.vay be attached to oppilcation.

ITEM 18

- NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE

- Any appilcation for a license or renewal of Ilconse is not complete without NRC Form 396.

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

For appilcations following a i

voluntary withdrawal or license dental or an upgrade appilcation, walvers may be granted on a 1

case basis if the original medical evaluation was performed within one year.

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

ITEM 19

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

o. Date and signature of appilcant certifying under penalty of perjury that the information provided on HRC Form 398 is true and correct.

Appilcant's signature also authorizes the NRC to submit results of examinations to appilcant's employer.

i b.

Date and signature of Training Coordinator AND Senior Management Representative on Site certifying, under penalty of perjury, that appilcant hoe successfully completed the facility licensee's requirements so be licensed as an Operator / Senior Operator pursuant to 10CFR553 and that the appilcant 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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