ML20214T020

Forwards Revised NRC Form 398 Re Licensee Personal Qualifications Statement.Rev Reflects Changes to 10CR55 Effective 870526 & Requires New Applicants to Complete Each Category Completely.Form to Be Used Beginning 870526

ML20214T020
Person / Time
Site:	Crane
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Standerfer F GENERAL PUBLIC UTILITIES CORP.
References
NUDOCS 8706100090
Download: ML20214T020 (17)

Text

l JUN 4 G87 Docket No. 50-320 GPU Nuclear Corporation ATTN:

Mr. F. Standerfer Director of TMI-2 P. O. Box 480 Middletown, Pennsylvania 17057 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 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.

5 p

0FFICIAL RECORD COPY OL MULTI LTR - 0041.0.0

1. l 05/29/87 8706100090 870604 PDR ADOCK 05000320 l

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GPU Nuclear Corporation 2

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

Sincerely, Origina1 Signed By:

Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

William Thompson Tra Public Document doom (ining Manager PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector Commonwealth of Pennsylvania cc w/o enclosures:

T. F. Demmitt, Deputy Director, TMI-2 R. E. Rogan, Licensing and Nuclear Safety Director J. J. Byrne, Manager, TMI-2 Licensing J. E. Frew, Defueling Director J. B. Lieberman, Esquire A. Miller. Manager, Plant Operations Ernest L. Blake, Jr., Esquire S. Levin, TMI-2 Site Operations Director bcc w/ enclosures:

OL Plant File Examiners RI: RP RI:CRP P

Lan mjd/gcb Kel r

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6/h/87 0FFICIAL RECORD COPY OL MULTI LTR - 0042.0.0 05/29/87

INSTRUCTIONS FOR COMPLETING A

NRC FORM 398, PERSONAL QUALIFICATIONS STATEMEMT-LICENSEE NEW APPUCANTS COVPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE LNSTRUCT ALL EOUCATION. TRAIN:NG ANO EXPERIENCE THAT YOU HAVE RECElVED UP TO THE OATE OF THIS AP RENEWAL. UPGRADEO. MULTI-UNIT. AND REAPPUCATION APPUCANTS. COMPLETE EACH CATEGORY OF INDICATE ONLY THE EDUCATION, TR AINING. AND EXPERtENCE YOU HAVE RECEIVED SINCE YOUR LAST APPUCATION. NOTE: See tem SPECIFIC INSTRUCTIONS FOR ITEMS 1119:

11-EDUCAT10N: tNCICATE BOTH ACADEMIC ANO VOCATION AL/ TECHNICAL POST HIGH SCHOOt. EDUC INDICATE THE NUMBER 05 viaRS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGRE PROVtOED FOR VOCATION AL/ TECH NICAL.EOUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR PO CONDITIONING / REFRIGERATION. OtESEL MECHANIC SCHOOL. ETC. INDICATE THE NUM8ER OF M A CERTIFICATE OR OEGREE W AS AWAROED IF ADDITIONAL SPACE IS NEECEO. CONTINUE UNDF A ITEM 17 12-TRAINING. iN THIS ITEM :NO:CATE THE TRAINING YOU HAVE RECELVED TO MEET THE REQUIREMEN BREAKOOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDAROS PLEASE REFER TO T CLARlFICATION. INCLUDE BOTH 8EGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEE ING NUMBER OF WEEKS IS PROVIDEO. IN AOCITION TO BEGINN;NG AND COMPLETlON DATES. TO ACCOUNT FOR INTERMITTENT T tFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERICO). THEREFO CICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL TIME TR AINING. T APPUED FOR CANNOT BE OOUBLE COUNTEO UNDER EXPERIENCE. ITEM 13.

ALL REOUAtlFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUAUFICATION ITEM. PLEASE AV tNG ALL THE TIME SPENT IN REQUAllFICAT10N TRAINING UNDER ITEM 12.6. REQUAUFICATION. EVEN THOUGH OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH POSITION HELO. COMPLETE ITEM 16. DO NOT OOUBLE COUNT TIME. IF YOU HAO OVE MONTHS SHOULO REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR THE NUMBER OF MONTHS RE*ORTED FOR A PARTICULAR TIME PERICO EXCEEO THE NUMBER OF MONTHS THAT A 14-FACluTY OPERATOR TR AINING PROGR AM. INOtCATE a GRAOUATE OFINPC ACCREOtTED OPERATOR TRAtNING PROG

b. CER-T3FIED !ON NRC FOAM 4741 OR NRC ApcROVED SIMULATION FAC!UTY iS USEO IN THE OPER ATOR TRAINING PROGRAM. IF YES IS CHECKEO IN BOTH ITEMS a ANO b. THEN ITEMS 11. EDUCATION,12. TRAINING.13. EXPERIENCE AND M FYPGR!fWF DETAILS r10 NOT HAVE TO SE COMPLETEO; EEIPT s muuJIC;G NST 3Tlit 16I TnE 'UtBER OF $1GNIFICANT CONTROL PA11PtWIONS UNU[il !TCM 12.3.

NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD, 15-FOR RENEWALS ONLY: ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF UC R EN EW AL.

16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERIOO FROM/TQFACluTY. AND A BRIEF DESCRIPTION OF OUTIES PERF WHILE SERVING IN TH AT POSITION. IF MORE SPACE IS NEEDEO. USE ITEM 17. OR IF NECESSARY ATTACH ACO(TIONiLL INFORMA 17-COMMEN7: USE THl$ $9 ACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPLICATI IF THE SPACE f 20 VIDEO IS NOT SUFFIC:ENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINAT10N BY FACIUTY UCENSEE. MUST ACCOMPANY THIS APPUCATION.

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

OETACH THESE INSTRUCTIONS AND SU8MIT THE COMPLETED NRC FORMS 398. IN TRIPUCATE fongsnaland two coo.es) AND 396 TO THE APPROPRIATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. SE2af eH31. enacted into law by Section 3 of et e Privacy Act of 1974 (Public Law S3-5791 the followmg is furnished to in-dividuele who supply enformation to the U.S. Nuclear Regulatory Commission on NRC Form 398. This information is maintemed in a system of records designated es NRC 16 and oeecnbod at a6 Federet Register a6717 (September 21. 19813.

1. AUTHORITY. Section 107 and 161(il of the Atomic Energy Act of 1954, as amended (42 U.S.C. 21n and 2201 (ill.

2. PRINCIPAL PURPOSES. The informanon will be coilected and evaluated for determming licensing eligibility and to generate statistical data and reports on licenomg actions.

3. ROUTINE USES. Information entered on thee form may be used to: (el determine if the individual meets the requiremente of 10 CFR Part 55 to be issued en operator's license: (b) provide researchers with informatson for statistical evaluatione related to selection. training, and eneminatson of f scitety operators: Icl provide f acility management with sufficient information to enroll the individuele in the licensed operator requalification progrem: (di provide for examinetton and testing metenal and obtain results from contractors.

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4. WHETHER OlSCLOSURE IS M AND ATORY OR VOLUNTARY AND EFFECT ON INOlVIOUAL OF NOT PROVIOING INFORM ATION: Disclosure is volunterY. However. if the information requested is not provided. NRC will not be able to eveiuste whether the application meets the requirements of 10 CFR Part 55.

5. SYSTEMS MANAGERS AND ADORESSES.

Regonae Admastrator. Reg.on i Regional Adminestrator. Regeon il

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631 Part Avenue 101 Marietta Street. Suite 2300 Kmg of Prussa PA 19406 Atlanta. GA wtTt Regonal Admenestrator. Region til Regional Admanestrator. Regen IV Regional Admastrator. Reg on v U.S. Nuclear Regulatory Commess.on U.S. Nuclear Requtatory Commessson U.S. Nuclear Regulatory Commiss cn 799 Roosevett Road 611 Ryan Ptaza Onve, Suste 1000 1450 Mena Lane. Suite 210 G6en Ellyn. iL 60137 An ngton. TX 76011 Wamut Crees. CA 94S96

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- ENCLOSURE 2 s-

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 Form 474 certified simulation facility.

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

Renumbered previous items 14 through 17 to 16 Items 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 Fonn 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 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."

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 Representative On Site."

FOR NRC USE Under waiver category combined " Oral" and

" Simulator" into " Operating".

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ENCLOSURE 3 PERSONAL QUALIFICATIONS STATEMENT - LICcNSEE 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 s 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.

s. New

- Applying for the first time at this facility OR if previously app) led 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.

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4

b. Renewal

- Now holds a license and i s 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.

l d.

Multi-unit

- Applying for a license on more than one unit OR ls 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.

e.

Reapplication

- 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 appilcant 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 ITEMS MUST BE COMPLETED ON A i

REAPPLICATION APPLICATION SUT NEED ONLY INCLUDE THE EDUCATION, j

TRAINING AND EXPERIENCE RECEIVED l

SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

i 3-j 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.

If denied a license for 2-Second the second time, the applicant must wait six months from the date of dental 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.

i 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 en 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 I

a. Operator

- Applying for an operator license.

j b.

Senior Operator

- Applying for a senior operator license.

c. Limited SRO

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

1 ITEM 6 PREVIOUS LICENSE (S) HELD

- To be completed if previously held a license (or instructor i

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 Certification or Limited 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).

c. Expiration Date

- Date of Ilconse expiration.

If severs 1 renewals have occurred, list only latest expiration date.

i l

d. Facility Docket No.

- Docket number of facility where appilcant held license (50-XXX).

Note:

If previously held license / instructor certification at a training canter, simulator, etc.,

where there is no facility docket number, urite in the name'.

NAME OF APPLICANT'S EMPLOYER ITEf 7

- 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.

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

ITEM 10 CURRENT POSITION AT FACILITY Note license type 11 required

a. Plant Superintendent by position.

b.

Assistant Plant i

Superintendent Note license type if required 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 1.

Instructor l

by position.

l

g. Senior Control Room Operator

- Positicn requires current senior lictnse for a plant with fuel in the reactor.

h.

Control Room Operator - Posit'lon requires current operator Ilconse for a plant with fuel in reactor, I. Aux 111ery Unit Operator / Trainee /

Turbine Building /

Equipment Operator (non-licensed operator)- Ensure description is detailed enough to allow evaluation of position.

J. Other (Specify)

- Ensure descripticn is detailed enough to tilow evaluation of position.

Note license type 11 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 cellsge successfully completed.

( F r e s hm a rs = 0 to 1 year Sophomore = 1 to 2 years Junior = 2 to 3 years Senior = 3 to 4 years Graduates 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 fleid majored ins number of years, ands highest degree obtained.

d.

Vocational / Technical Type of Training-Vocational / technical training schools, inc3uding allitary schools, appilcable to the operation of a

pcuer plcnt.

Includo#such j

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 Heeks, 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> / day = 1 month) j Certificate Received

- Indicate if certificate uns 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 l

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 largsr time span than the actual number of weeks spent in full-time training.

Time In training for the license spplied for cannot be double counted under Experience, Item 13.

REQUALIFICATION training time is be accounted for in Item 12.6.

i 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.

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

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

Hot Ilcense candidates must manipulate the controls under direct supervision cf a licensed operator at the individual's duty station for a verlety of plant operations.

Cold 11:ense 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 simulators 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 facilities without a plant referenced simulator, startup certification must be obtained from the organization at which the startup demonstration was performed.)

Number of Reactivity Number of actus! reactivity Manipulations:

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.

i

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 simulator time.

7-Other (Specify)

- Ensure description is detailed i

enough to allow evaluation.

Include number of research reactor startups, if performed.

)

i ITEM 13 EXPERIENCE

- Experience is indicated in months.

i For each position held, list the l

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 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 IIsted in 1-5.

NAVY Non-nuclear military power experience should be ilsted 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.

1 -

1

)

a) Graduate of INPD Accredited Operator i

Training Program "X" Yes or No if the appilcant is a graduate of an INPD accredited operator training program.

(NOTE:

INPD accredited means accreditation by the National Nuclear Accrediting l

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 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 license.

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 appilcation form.

If space provided is not sufficient, extra pages may be attached to appilcation.

ITEM 18

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

- Any appilcation for s 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 voluntary withdraws! or license denial or en upgrade appilcation, waivers may be granted on a case basis if the original medical evaluation was performed within one year.

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

I

l

~

_g.

3-EWS/PPWS Gus11 fled to direct and supervise the operations of a Navy Propulsion plant.

Quellfled to direct and supervise Navy

)

4-ERS/CRW 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 propulslan/ 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.

1 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. (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 des ription is detailed 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 Id (Experience Details) DO NOT have to be completedi except new applicat;ons must still include the number of significant control manipulations under Ittm 12.3,

ITEM 19

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

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

Applicant's signature also authorizes the NRC to submit results of examinations to applicant'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 appilcant has a need for this license to perform assigned duties.

Also certifies that facility ul11 be evallwble for examinations.

c. RENEWAL ONLY - Must be signed and dated by Training Coordinator AND Senior Management Representative On Site certifying, under pensity 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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