ML20214T843

Forwards Revised NRC Form-398, Personal Qualifications Statement - Licensee, Reflecting Changes to 10CFR55 Effective 870526

ML20214T843
Person / Time
Site:	Pennsylvania State University
Issue date:	06/03/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Hosler C PENNSYLVANIA STATE UNIV., UNIVERSITY PARK, PA
References
NUDOCS 8706100447
Download: ML20214T843 (17)

Text

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Docket No:

50-05 The Pennsylvania State University ATTN: Dr. Charles L. Hosler, Jr.

Vice President for Research and Dean of the Graduate School University Park, Pennsylvania 16802 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 L

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 cf significant control manipulations l

l 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.

4 The enclosed applications are for your use. Additional copies can be obtained by writing to Vfvian Miller, U.

S.

Nuclear Regulatory Co::.mi ssion, Document i

Management Branch, lhil Stop W-548, Washingtor., D.C. 20555.

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

Sincerely, i

Oriainalsi edsy SamuelJ.Co$ lins,DeputyDirector i

Division of Reactor Projects i

Enclosures:

As stated cc w/ enclosures:

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R. W. Granlund, University Health Physicist

.Dr. Marcus H. Voth, Director, Breazeale Nuclear Reactor j

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INSTRUCTIONS FOR COMPLETING NRC FORM 338. PERSONAL QU ALIFICATIONS STATEMENT-LICENSEE NEW APPUCANTS. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWsNG THE INSTR ALL EDUCATION. TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVE 0 UP TO THE DATE OF THIS A RENEWAL. UPGRADED. MULTI UNIT. AND REAPPUCATION APPUCANTS. CCMPLETE EACH CATEGORY INO8CATE ONLY THE EDUCATION, TRAINING, AND E.XPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPUCATION. NOTE: Se SPECIFIC INSTRUCTIONS FOR ITEMS 1113:

INDtCATE 80TH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FO 11-E DUCATION:

INCICATE THE NUMBER OF VEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGRE PROVtOEO. FOR VOCATIONAL / TECHNICAL EDUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR P CONOITIONING/REFRtGER ATION. CIESEL MECHANIC SCHOOL. ETC. INO8CATE THE NUMBER OF M A CERTIFICATE OR OEGREE W AS AW ARDED IF ADDITIONAL SPACE (S NEEDEO. CONTlNUE UNOFR ITEM 17 12-TRAINING. iN THIS ITEM ;NotCATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1.

BREAKDOWN OF TR AINING IN THIS CATEGORY PARALLELS THE ANS STANDAR05: PLEASE REFER TO CLARIFICATION. !NCLUCE BOTH EEGINNING AND COMPLETION DATES AND THE TOTAL NUM8ER OF W ING. NUM8ER OF WEEKS IS PROVfCEO. IN ADDITION TO SEGINNING AND COMPLETION CATES. TO ACC IFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERIODI. THERE CICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL TIME TR AINING APPUED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.

ALL RECUAUFICATION TRAINING TiMEIS TO BE ACCOUNTED FOR IN THE REQUAUFICATION : TEM. PLEASE ING ALL THE TIME SPENT IN REQUAUFICATION TRAINING UNDER ITEM 12 6. REQUAUFICATICN. EVEN THOUG OR SIMULATOR TIM 5 13-EXPERIENCE: FOR EACH POSITION HELD. COMPLETE ITEM 16, DO NOT DOUBLE COUNT TIME (F YOU HAD OVERLAPP1NG CUTIES. TH MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTIC THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERICO EXCEED THE NUMBER OF MONTHS TH AT 14 FAC1UTY OPERATOR TRAINtNG PROGR AM. INOICATE

a. GRAOUATE OC INPO ACCREDITED OPERATOR TRAINING PROGRAM: ANOb. CER-TIFiED fCN NRC FORM 47a# OR NRC APPROVED SIMULATION FACIUTY IS USED IN THE OPER ATOR TRAINING PROG IN SOTH ITEMS a AND 0. THEN ITEMS 11. EDUCATION 12. TRAINING.13. EXPERIENCF ANO 16 FxP5RirNCF 057 AILS no COMPLETEC; icIPT iiG ANCMIC:G MT IT!il IELU;E inE 'UtBER OF 5!GNIFICMT Coret FMIPULAttons uwtit ITEM 12.3.

NOTE: INPO ACCREDITED MEANS ACCRE0lTATION BY THE NATIONAL NUCLEAR ACCREDITING 80ARO.

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

16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERICO FROM/TQFACIUTY, AND A BRIEF OESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEEDED USE ITEM 17. OR IF NECESSARY ATTACH A00(TIONAL INFORMATI 17-COMMENTS: USE THis SP ACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPUCAT10 IF THE SPACE PROVIOED iS NOT SUFFICENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 396. CERT 1F1 CAT 10N OF MEDICAL EXAMINATION BY FACluTY UCENSEE. MUST ACCOMPANY THl3 APPUCAT10N.

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

MENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS ANO SUBMtT THE COMPLETED NRC FORMS 398. IN TRIPUCATE tongmaland two coo.esJ AND 396 TO THE APPROPRIATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. SE2mieH31. enacted into law ry Section 3 of the Pnvecy Act of 1974 (Public Law $3-5791. the fo4 towing is furnished to m-dividuals who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. This inf ormation is memtemed in a system of records designated es fWRC 16 and desentped at a6 Federal Register a6717 (September 21, 1981).

1. AUTHORITY. Section 107 and 161(1) of the Atomic Energy Act of 1964. as amended (42 U.S.C. 2171 and 2201 till.

2. PRINCIPAL PURPOSES. The informenon will be collected and evaluated f or determming licensmg esigib.tity and i2 generate statistical date and reports on liconemg actions.

3. ROUTINE USES. Information entered on this form may be used to: tal determine if the individuet meets the requiremente of 10 CFR Part 56 to be issued en operator's license: (b) provide researchers with information for statistical evolustione rotated to selection. trainmg. and enemination of f acierty operatore: (c) provide f acility management with sufficient informeteon to enro64 the individuals in the licensed operetot recualification program: (di provide for enemination end testing metenei and obtain results from contractors.

4. WHETHER OISCLOSURE IS M ANDATORY OR VOLUNTARY AND EFFECT ON INOlVIOU AL OF NOT PROVIOtNG INFORM ATION: Disclosure is vo6untary. However. if the information requested is not provided. NRC will not be obie to eva6uate whether the app 6ication meets the requirements of 10 CFR Part 56.

5 SYSTEMS MANAGERS AND ADORESSES:

Regional Admenstrator. Reg on i Regional Admenestrator. Reg.on it U.S. Nuclear Regulatory Commes on U.S. Nucteer Regulatory Commess.on 631 Partr Avenue 101 Marietta Street. Sv.te 2900 King of Prussaa. PA 19a06 Atlanta. GA wtn Aegsonal AdmenrStrator. Region ill Regeoned Admeustrator. Region IV Regional Admm.strator. Region V U S. Nuclear Regulatory Commss.on U.S. Nuchner Regulatory Comm ss.on U.S. Nucteer Regulatory Commess.on 799 Roosevest Road 611 Ryan Pteza Onve. Suite 1000 1450 Mana Lane. Su.te 210 G6en Ellyn il 60137 Art ngton. TX 76011 Wainut Creet. CA 94596

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q ENCLOSURE 2 8

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 Item 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 originally 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 infomation 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 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."

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".

ENCLOSURE 3 PERSONAL QUALIFICATIONS STATEMENT - LICENSEE NRC FORM 398 (REY 4/87) t 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"

applicable boxes:

Applying for a license at 1-Hot plant that has achieved

.a initial criticality.

This should be completed for each appilcation.

Applying for a license at 2-Cold a_ plant that has not achieved initial criticality. This should be completed for each appilcation.

Applying for the first time

a. New 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.

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b. Renewal

- Now holds a IIconse and is a

renewing that same type of Ilcanse.

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 ilsted 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.

Reapp11 cation

- 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 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.

If denied a license for the 1-First first time, the appilcant must wait two months from the date of denial letter before l

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

If denied a license for 3-Third the third time, the applicant must wait two years from the date of denial letter before reapplying for a license.

f. Walver Request

- NOTE:

Justification for any waiver request is required under Item 17.

1-Written

- To request a waiver on entire written exam or on part of the written exam.

(Category (s) for which waiver requested should be specified in space provided.)

2-Operating

- To request a waiver 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 s.

Operator

- Applying for en operator license.

i b.

Senior Operator

- Applying for a senior operator license.

c. Limited SRO

- Applying for a limited 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 if this license was for RO or SRO.

If this was for

Instructor Certification or Limited Senior Operator, plasse write in.

If a denial letter was lssue'd, 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, list only latest expiration date.

Docket number of facility where d.

Facility Docket No.

appilcant held license (50-XXX).

Note:

If previously held IIconse/ 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.

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

CURRENT POSITION AT FACILITY ITEM 10 Note license type if required a.

Plant Superintendent by position.

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b.

Assistant Plant Note license type if required Superintendent by position.

c.

Shift Supervisor

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

Note license type if required d.

Staff Engineer by position.

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Shift Technical l

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

f.

Instructor Note license typa if required j

by position.

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g. Senior Control Room Operator

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

reactor.

h.

Control Room Operator - Posit'lon requires current operator licensa for a plant with i

fuel in reactor.

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1. Auxillary 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 Sophomores 1 to 2 years Junior = 2 to 3 years Senior = 3 to 4 years Graduate = 4 years or more) i

c. Major Areats) of Study-Engineering

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

Other

- Other field majored ins J

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 p: wor plant.

Includo such programs as nuclear power school, sir conditioning / refrigeration school, diesel mechanic school, instrumentation and control maintenance, etc.

Number of Months-Calculate the approximate number of full months applicant eceived 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 nonth 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 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 f

power plant systems and system and component malfunctions.

Observation

- Planned systematic observation l

training on accessible plant l

equipment.

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i 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 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.

t Simulator Operations Practice in manipulating plant (Includes Classroom) 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 than two simulators specify the two most recent only.

Startup Certification "X"

Yes or No.

(Notes For Completed facilities with plant referenced simuistors, certification of startup l

training will be provided by the facility organization.

For those i

facilities without a plant referenced l

simulator, startup certification must be obtained from the organization at which the startup demonstration was performed.)

l Number of Reactivity l

Manipulations:

- Number of actual reactivity j

manipulations in which the applicant 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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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 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 i

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.

NAVY Non-nuclear allitary 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.

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- 10 a) Graduate of INPO Accredited Operator Training Program "X" Yes or No if the appilcant 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 l

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 - HOURS OPERATED FACILITY:

- The approximate number of hours appilcant has operated the facility under his existing IIcense.

Include position title, time ITEM 16

- EXPERIENCE DETAILS period (from/to), and description of duties performed while serving in that position.

Item 17 should be used if more space is needed.

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 i

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 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 applications following a 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 waiver is requested, Item 4.f.4 should be marked.

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

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

5-0THER (Specify)

Ensure description is detailed enough to allow evaluation.

FOSSIL 6-Operator Navy or commercial non-nuclear propulsion / power plant operation.

7-Supervisor Authorized to direct and supervise non-nuclear 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. (Nonlicensed)

Operator Personnel used in direct support of plant operations as directed by licensed operators.

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

16-Other (Specify)

Ensure description is detailed enough to allow evaluation.

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

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

ITEM 19

- SIGNATURES REQUIRED Any false statement or ommission in this document, including attachments, any 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.

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 applicant has successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant to 10CFR551 and that the appilcant has a need for this license to perform assigned duties.

Also certifies that facility ul11 be available for examinations.

c. RENEWAL ONLY - Must be signed and dated by Training Coordinator AND Senior Management Representative On Site certifying, under penalty of perjury, that appilcant meets the approved requalification program (with any exception noted in Comments, Item 17) as required by section 50.54(1-1) of 10CFR50 and has discharged licensed responsibilities competently and safely.

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