ML20214T355

Forwards Revised NRC Form 398, Personal Qualifications Statement - Licensee. Rev Reflects Changes to 10CFR55 Effective 870526.Requests All Applications Be Submitted on Revised Form Beginning on 870526

ML20214T355
Person / Time
Site:	Vermont Yankee File:NorthStar Vermont Yankee icon.png
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Murphy W VERMONT YANKEE NUCLEAR POWER CORP.
References
NUDOCS 8706100220
Download: ML20214T355 (18)

Text

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's JUN 4 1987 Docket No. 50-271 Vermont Yankee Nuclear Power Corporation ATTN:

Mr. Warren P. Murphy Vice President and Manager of Operations RD 5, Box 169 Ferry Road Brattleboro, Vermont 05301 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 reaoplication applicants are requ':ed 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-l 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 l

Management Branch, Mail Stop W-548, Washington, D.C. 20555.

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l OFFICIAL RECORD COPY OL MULTI LTR - 0026.0.0 05/29/87 g

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.Vennont Yankee Nuclear Power Corporation 2

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

Sincerely, 0.rigimi Signed Bys

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Samuel J. Collins, Deputy Director Division of Reactor Projects-

Enclosures:

'As stated cc w/ enclosures:

4 R. W. Spinney, Training Manager Public. Document Room (PDR)

LocalsPublic Document Room (LPDR)

Nuclear Safety Information Center?(NSIC) #

NRC Resident Inspector'

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cc w/o enclo~sures:

R. W. Capstick, Licensing Engineer-J. Gary Weigand,, President and Chief Executive _0fficer J. P. Pelletier; Plant Manager Donald Hunter,.Vice President '

4 State.of New flampshire (w/ enclosures)

States:of Vermont

-(w/ enclosures)

Cort Richardson, Vermont Public Interest Research Group Inc.

Gerald Tarrant Commissioner, Department of Public Service bec w/ enclosures:

OL Plant File Examiners RI:SRP RI:

P Larig p/mjd/geb Ke' r

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.QI h/w/87

/87 6/ h/87 0FFICIAL RECORD COPY OL MULTI LTR - 0026.1.0 05/28/87

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INSTRUCTIONS FOR COMPLETING NRC FORM 338. PERSONAL QUALIFICATIONS STATEMENT-LICENSEE NEW APPUCANTS COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE INSTRUCTIO ALL EDUCATION. TRAINING ANO DPERIENCE THAT YOU HAVE RECEfVED UP TO THE DATE OF THIS APPU RENEWAL. UPGRADEO. MULTI-UNIT. AND REAPPUCATION APPUCANTS COMPLETE EACH CATEGORY OF (NOiCATE ONLY THE EDUCADON. TRAINING. ANO EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST A SPECIFIC INSTRUCTIONS FOR ITEMS 1119 INDICATE SOTH ACADEMIC ANO VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCAT ON FOR 11 -E DUCAT 10N:

INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGRE PROvlOED FOR VOCATIONAUTECHNICAL EDUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR POW CONDITIONING / REFRIGERATION. DIESCL MECHANIC SCHOOL. ETC. INDICATE THE NUMBER OF MON A CERTIFICATE OR DEGREE W AS AWAROED IF ADDITIONAL SPACE IS NEEDEO. CONDNUE UNOFR ITEM 17 12-TRAINING. IN THiS ITEM :NotCATE THE TRAINrNG YOU HAVE RECEIVED TO MEET THE REQUIREMEN OREAKOOWN OF TRAINING 4N THl$ CATEGORY PARALLELS THE ANS STANDAROS PLEASE REFER T CLARIFICATION INCLUCE BOTH SEGINNsNG AND COMPLETlON DATES AND THE TOTAL NUMBER OF WEE ING. NUMBER OF WEEKS IS PROVIDEO, IN ADOtTION TO BEG;NNING AND COMPLETION DATES. TO ACCOUNT FOR INTERMITTE IFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERIOOL THEREF OsCATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENTIN FULL. TIME TRAINING APPUEO FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.

ALL REOUALIFICATION TR AINING TIME IS TO BE ACCOUNTED FOR IN THE REOUAUFICATION ITEM. PLEA tNG ALL THE TIME SPENT IN REQU AllFICATION TRAINING UNDER ITEM 12.6. REQU ALIFICATION. EVEN THO OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH POSIDON HELO. COMPLETE ITEM 16. 00 NOT OOUBLE COUNT DME. IF YOU HA MONTHS SHOULD REFLECT THE PROPORTION ATE AMOUNT OF TIME YOU WERE AS$1GNED TO THOSE PARDC THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUM8ER OF MONTHS T e GRAOUATE OFINPO ACCREOfTE0 0PERATOR TRAIN:NG PROGRAM: ANO b.CER 14 FACIUTY OPERATOR TRAINING PROGRAM. lNotCATE OR NRC APPROVED SIMULATION FACiUTY t$ USED IN THE OPERATOR TRAINING PROGRAM. fF YES TlFIED f 0N NRC FORM 474 IN BOTH ITEMS e ANO b. THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCF AND 16 FXP8 AIFNCF OF COMPLETE 0; (zwf en ANCAi!C4 K,ST si!LL IMLUGE Trit vBER OF sicNIF! CANT CONTROL MArilPutAf10N5 uNuta ITCM 12.3.

NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL, NUCLEAR ACCRE0tTING 80ARD.

ENTER THE APPROXIM ATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR (SSUANCE OF 15-FOR RENEWALS ONLY:

R ENEWAL.

16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERIOO FROM/TO,FACluTY. AND A BRIEF DESCRIPTION OF QUTIES PERFORMED WHILE SERVING IN THAT POSIDON. IF MORE SPACE IS NEEDEO. USE ITEM 17, OR IF NECESSARY ATTACH A00lDONAL INFORMATION.

17-COMMENTS: USE THIS SPACE TO tNCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS O IF THE SPACE PROVIDED IS NOT SUFFICIENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION 8Y FACluTY UCENSEE. MUST ACCOMPANY THIS APP 19-SIGN ATURES: SIGN AND OATE ITEM 13a. O8TAIN YOUR TRAINING COOR0lNATOR'S SIGNATURE AND THAT OF MENT REPRESENTATIVE ON SITE.

OETACH THESE INSTRUCTIONS AND SU8MIT THE COMPLETED NRC FORMS 398. IN TRIPUCATE (ong rial and two coo-rs/ AND 396 TO THE APPROPRI ATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. 552eleH3L enacted into law by Section 3 of the Pnvecy Act of 1574 (Public Law $3-579L the following is furnished to m.

deveduele who supply mformation to the U.S. Nucteer Regulatory Commission on NRC Form 398. This intarmation se memteened in a system of recorde desegnated se NRC 14 and desenbod et es Federal Register e6717 ISeptember 21. 19818.

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1. AUTHORITY. Section 107 and 16110 of the Atomic Energy Act of 1964. es amended M2 U.S.C. 2137 and 2201 liH.

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2. PRINCIP AL PUR POSES. The informenon will be cosiected end evaluated f or determemng licensing eligibiletY and to generete statistices date and reports on licensmg actione.

3 ROUT 1NE USES. leformation entered on thee form may be used to: let determme if the mdividual moete the requiremente of to CFR Part 55 to be issued on operefor's license: lbi provide reeeerchere with mformation for statistical evoluetione feisted to selection, trainmg. and e nemmeteon of f scritty operatore: tel provide f ecility menegement with sufficient informetion to oneoil the individuele in the licensed operetot requalification progrem: (d) provide for enemination and testing metenet and obtain results from contractore.

4 WHETHER OISCLOSURE l$ M ANDATORY OR VOLUNTARY AND EFFECT ON INolVIOUAL OF NOT PROVIDING INFORM ATIO se voluntary. However. If the information roovested is not provided. NRC will not be able to evolutte whether the oppfecation meets the teoveremente of 10 CFR Part $3 i

I 5 SYSTEMS MANAGERS AND ADORESSES.

Reg.ones Admin,strator Regon i A*geones Administrator. Region 11 U S. Nuclear Regutatory Comm.smon U S. Nucteer Regulatory Commessen 101 Mariette Street. Suete 2300 631 Pere Avenue Afterte. GA 30123 Kong of Pruss e P419406 Regenei Adm+nestrator Reg.on ill Regione# Ademnestrator. Regon IV Regened Admenestrator, Reg'on V U S. Nuoser Reguutory Commesmon U.S. Nucwer Requwtory Commeoson U.S Nucteer Requietory Commeon 77} Rooseveet Anad 611 Ryan Ptese Drive. Suite t000 1450 Maria Lenn. Suite 210 W ams Crees. CA 94S96 i

Geen flivn. IL 60137 Art.ngton. TX 7(411

s o,Af, AaCaivsotTe se=eeves oM soAM 3 U. S. NUCLEAR MOULATORY COMMISalON Aes, see,o as.

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.o ENCLOSURE 2 SUMARY OF' CHANGES TO NRC FORM 398 l

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.

Changed to read "NRC Fom 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 Fonn 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 l

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 j

attachments is true and correct. Changed signature block from " Highest Level of Corporate Management for Plant Operation" to " Senior Management Representative On Site."

l FOR NRC USE Under waiver category combined " Oral" and l

" Simulator" into " Operating".

=-.

ENCLOSURE 3 t

9-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 g

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.

CITIZENSHIP.

If other then U. S. Citizen, ITEM 2 citizenship must be specified.

DATE OF BIRTH.

ITEM 3 TYPE OF APPLICATION.

ITEM 4 "X" app 11 cable boxes Applying for a license et 1-Hot a plant that has achieved inittel criticality.

This should be completed for each appilcation.

i Applying for a license at 2-Cold a plant that has not achieved inittel criticality. This should be completed for each oppilcation.

Applying for the first time

e. New et this facility OR If previously i

applied for a license but withdrew (write in "previously withdrew" next to Now).

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 l

i ITEM 14.

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- Now holds e alconse and is i'

b. Renewal renewing that some type of Ilconse.

ALL ITEMS MUST BE COMPLETED ON A RENEWAL APPLICATION BUT NEED ONLY INCLUDE TNE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE THE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

c. Upgrade

- Now holds en operator's license end is applying for e 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 then 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 TNE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

e. Reapplication

- Previously took e licensing exam and was denied a license and is now reapplying for that some type of Ilconse et the some feellity.

The reapplication should Identify those areas in which the oppilcant demonstrated weaknesses during the previous eneminetlon and the additions! 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 TNE 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 s

first time, the appilcant must Walt two months from the date of denial letter before reapplying for a license.

2-Second

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

3-Third

- If denied a license for the third time, the appilcant must Walt two years from the date of dental letter before reapplying for a lice 1se.

f. Walver Request

- NOTE:

Justification for any walver 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 walver requested should be specified in space provided.)

2-Operating

- To request a walver on an operating exan.

3-Eligibility

- To request a walver on eligibility requirements.

4-Other

- To request any other wolver, 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 e ilmited senior operator license (e.g. fuel handler).

PREVIOUS LICENSE (S) HELD ITEM 6

- 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 11 this license was for RO or SRO.

If this was for

4 Instructcr Cortificctisn er Llolt0d Senior Operator, plasse write in.

t*

If a denlel letter was issued, e 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 renewat number, if any, (i.e., XXXXX-3).

c. Empiration Date

- Date of Ilconse empiration.

If severe 1 renewels have occurred, list only latest expiration date.

d. Facility Docket No.

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

Note If previously held license / Instructor certification at a training center, simuistor, etc.,

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

NAME OF APPLICANT'S EMPLOYER ITEM 7

- Name end address of current employer.

NAME OF APPLICANT'S FACILITY ITEM 8

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

ADDITIONAL FACILITY DOCKETS ITEM 9

- If applying for multi-unit license ALL oppilcoble additional docket numbers must be entered.

ITEM 10 CURRENT POSITION AT FACILITY

a. Plant Superintendent

- Note license type 11 required by position.

b. Assistent Plant Note license type 11 required Superintendent i

by position.

Position requires current

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

i Note license type if required

d. Staff Engineer by position.

e. Shift Technical Advisor / Shift Engineer-Note license type 11 required by position.

Note license type if required f.

Instructor by position.

-5

g. Senior Control Room t

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. Auxl11ery Unit Operator / Trainee /

Turbine Building /

Equipment Operator (non-11 censed operator)- Ensure description is detalled enough to allow evaluation of position.

J. Other (Specify)

- Ensure description is detalled enough to allow evaluation of position.

Note license type if required by position.

ITEM 11 EDUCATION

a. Nigh 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)

c. Major Ares (s) of Study-Engineering

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

Other

- Other field majored ini.

number of years, andt highest degree obtained.

d. Vocational / Technical Type of Training-Vor.ational/ technical training schools, including allitary schools, appilcable to the operation of a p;r0r plcnt.

Includ3 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.

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-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.

7 3-Operating Practice

- Trelning in operating practices in the control room for which the f

candidate ul11 Ilconse and at a plant referenced simulator if one is evallable.

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

Not Ilconse condidates 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 preoperational testing program.

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

Simulator Operations (Includes Classroom)

- Practice in mentpulating plant controls during normale abnormal and emergency condition, on a plant referenced simulator.

Simulator Name(s)

- Specify the simulator (s) where training was received.

If more then two simulators specify the two most recent only.

Startup Certification Completed "X"

Yes or No.

(Notes For facilities with plant referenced simuistorse certification of startup training will be provided by the facility organisetlen.

For those facilities without a plant referenced simuistor, startup certification must be obtelned from the organization at which the startup demonstration was performed.)

Number of Reactivity Manipuistions

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

(Details should be provided in Commentse Item 17.)

4-SRO Instruction

- Instruction in the duties of a senior operator.

.g.

o 5-Extra Person on Shlft - Must be a minimum of three months on shift performing the actual t

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.

4-Requs11fication

- ALL requalifications tralning, including classroom and simulator time.

7-Other (Specify)

- Ensure description is detalled enough to allow evaluation.

Include number of research reactor startups, if performed.

EXPERIENCE

- Experience is Indicated in months.

ITEM 13 For each position held, list the month / year to cover the period you were quellfled for that posltion.

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 dutiese 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.

M111tery nuclear pouer experience should be ilsted in 1-5.

NAVY Non-nuclear al11tery power experience should be listed under Fossil 4-9.

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.

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

(NOTE:

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

b) Certlfled 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.

ITEM 15 -

FOR RENEWALS ONLY - NOURS OPERATED FACILITY

- The appronlaste number of hours appilcant has operated the facility under his existing Ilconse.

ITEM 16

- EXPERIENCE DETA!LS

- 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 sufficiente extra pages may be attached to application.

ITEM 18

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

- Any appilcation for a license or renewal of Ilconse is not complete without NRC Form 896.

A medical is good for six months from the date the phys' clan signs it.

For applications following a voluntary withdrawal or license denial or en upgrade application, Walvers may be granted on a case basis 11 the original medical evaluation was performed within one year.

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

.g.

i 3-EWS/PPWS Quellfled to direct and supervise the operations of a Navy Propulslon plant.

4-ERS/CRW Quellfled to direct and supervise Navy Propulslon plant operations outside the maneuvering eres.

S-0THER (Specify)

Ensure description is detailed enough to allow evolustion.

FOS $1L 6-Operator Navy or commercle! non-nuclear propulsion / power plant operation.

7-Supervisor Autherlaed to direct and supervise non-nucteer operators.

8-Plant Staff Non-nucteer power plant staff experience.

9-Other (Specify)

Ensure description is detailed enough to allow evolustion.

COMMERCIAL NUCLEAR (Incitiding 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 welld 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 et the feel 11ty and involved in the day-to-day plant operational (engineering) staff work.

14-Auu./ Equip. (Nonllcensed)

Operator

- Personnel used in direct support of plant operations as directed by Alconsed operators.

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

16-Other (Specify)

- Ensure description is detalled enough to allow evolustion.

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

12 (Trainingle 13 (Euperience), and 16 (Euperience Details) 00 NOT have to be completodi except new applications nust still include the number of significant control manipulations under Item 12.3,

- II.

ITEM 19

- $1GNATURES REQUIRED Any falso statement or ommission in this documente including attachments, Cay be subject to civil and criminal sanctions.

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

t Applicant'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 10CFR55) and that the appilcant has a need for this license to perform assigned dutles.

Also certifies that facility Wi!! 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 Alconsed responsibilltles competently and safely.

,