ML20214T898

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

ML20214T898
Person / Time
Site:	Rhode Island Atomic Energy Commission
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Dimeglio A RHODE ISLAND, STATE OF
References
NUDOCS 8706100469
Download: ML20214T898 (17)

Text

-__

d o

JUN 4 1937 Docket No: 50-193 Rhode Island Atomic Energy Commission ATTN: Mr. A. Francis DiMeglio, Director Nuclear Science Center South Ferry Road Narragansett, Rhode Island 02882 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. Enclosure 3 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.

8706100469 870604 PDR ADOCK 05000193 P PDR h '

t 0FFICIAL RECORD COPY OL MULTI LTR - 0059.0.0 06/04/87 1

3-Rhode Island Atomic Energy Commission 2 If you have any questions regarding this form, please contact Robert M. Keller-at 215-337-5211. l Sincerely, D a,g, g n is.gned by Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

Professor George Seidel, Chairman, RIAEC Dr. Stephen Mecca, Commissioner, RIAEC John S. Pascalides, Commissioner, RIAEC Dr. Vincent C. Rose, Commissioner, RIAEC Dr. Stanley J. Pickart, Physics Department Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

State of Rhode Island bec w/ enclosures:

OL Plant File Examiners RI: P RI P RP La /mjd/geb K r 11 s 6/ /87 6/ 87 6/ 5 /87 0FFICIAL RECORD COPY OL MULTI LTR - 0060.0.0 06/04/87

e INSTRUCTIONS FOR COMPLETING NRC FORM 338 PERSON AL QUALIFICATIONS STATEMENT-LICENSEE THIS sS TO INCLUDE NEW APPLICANTS. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE INSTRUC ALL EDUCATION. TRAINING ANO EXPERIENCE THAT YOU HAVE RECEiVEO UP TO THE OATE OF RENEWAL. UPGR ADEO. MULTI. UNIT. ANO REAPPUCATION APPUCAMTS. NOTE:

TRAINING. AND EXPERIENCE YOU HAVE RECEIVEO SINCE YOUR LAST APPt.lCATION COMPLETESee item 14 EACH INOICATE ONt,Y THE EDUCATION SPECIFIC INSTRUCTIONS FOR ITEMS f f.11:

OF STUOY.

11 - E OUCA T10N: INOICATE BOTH ACADEMIC AND VOCATIONAL' TECHNICAL POST HIGH SCHOOL EDUCATION CODE FO9 4NDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST PROVIDEO FOn VOCAflONAL1 TECHNICAL EDUCAitON. INCLUDE PROGRAMS SUCH AS NUCLE CONDITIONtNG/ REFRIGERATION. OtESEL MECHAN #C SCHOOL. ETC. IN06CATE THE NUMBE A CERTIFICATE OR DEGREE V. AS AW AROED tF AOOITIONAL SP ACE IS NEEDEO. CONTINUE UNOFR ITEM 1 RECEIVED TO MEET THE REQUIREMENTS OF ANSL N181, ANS 3.1. THE 12-TRAININO. IN THis ITEM ;NO!CATE THE WINING v00 HAVF BREAKOOWN OF TRAININGIN THIS CATEGORY PARALLELS THE ANS STANDAROS PLEASE REF CLARIFICATION. INCLUOE BOTH BEGINNING AND COMPLETION OATES AND THE TOTAL NUMB G ING. NUMBER OF WEEKS ($ PROVIDED. fN AOOITION TO 8EGINNING ANO COMPLETION SDATES. MAY IN- TO tFOR EXAMPLE. FOUR WEEKS OF CLASSROOM TR AINING SPREAD OVER A TWO MONTH PERiOOL THE OICATE A LARGER TIME SPAN TH AN THE ACTUAL NUM8ER OF WEEKS SPENT IN FULL-TIME TR A APPUEO FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.

ALL REOUAurlCATiON TR AINING TIME IS TO BE ACCOUNTED FOR IN THE REOUAUFICATION ITEM P ING ALL THE TIME SPENT IN REOUAUFICAT10N TRAINING UNOER ITEM 12.6. REQUAUF#CATsON. EVE OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH POSITION HELO. COMPLETE ITEM 16. 00 NOT OOUBLE COUNT TIME. IF Y MONTHS SHOULO REFLECT THE PROPORT10NATE AMOUNT OF TIME YOU WERE ASSIGNED TO THO THE NUMBER OF MONTHS REPORTfD FOR A PARTICULAR TIME PERICO EXCEED THE NUM8ER OF M 14 FACIUTY OPERATOR TRAINING PROGRAM. INOiCATE a GRADUATE OFINPO ACCREDITED OPERATOR TRAINING PROGRAM: AND b.CE TIFIED 'ON NRC FORM 4741 OR NRC APPROvEO SIMULATION FACIUTY iS USED FYPFRIFNCF OrTAIN L3 THE no NOT OPER HaVE TOATOR BE TR IN SOTH ITEMS a ANO b. THEN ITEMS tt. EOUCATION.12. TR AINING.13. EXPERIENCE ANO Ifi COVPLETEO; Ermt m An.;c.;1cm %5T 1;til licuici tnt aim 8Ea of $1GNIFICANT CONTROL *AMIPUULTION5 UNUER ITN 12.3.

NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATION AL NUCLEAR ACCREDITING BOARD.

15-FOR RENEWALS ONLY: ENTER THE APPROxlMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE R EN EW AL.

16-EXPERIENCE DETAILS: INCLUDE POSITION TITLE. TIME PERIOO FROM/TO,FACIUTY AND A GRIEF OESCRIPTION OF OUTIES PERFORMEO WHILE SERVING IN TH AT POSITION. IF MORE SPACE IS NEEDEO. USE ITEM 17. OR IF NECESSARY ATTACH 17-COMMENTS: USE THIS SP ACE TO INCLUDE ANY EXTR A INFORM ATION OR CLARIFICATION FOR OTHER IF THE SPACE PROVIOED IS NOT SUFFIC:ENT. YOU MAY ATTACH EXTR A INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 336. CERTIFICATION OF MEDICAL EXAMINATION BY FACiUTY UCENSEE. MUST ACCOMPANY THIS APPUCATION, 19-SIGN ATURES: SIGN ANO D ATE ITEM 194. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE ANO TH i MENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMtf THE COMPLETED NRC FORMS 336. IN TRIPUCATE (ongnaland two cooesJ ANO 236 TO THE

)

j APPROPRI ATE REGIONAL ADMINISTR ATOR.

PRIVACY ACT STATEMENT Pursuant to U.S C. 552MeH3L enacted into law by Section 3 of the Pnvecy Act of 1974 (Public Law $1573), the following se furnished to in-deveduels who supply information to the U.S. Nuclear Requietory Commession on NRC Form 238. This information se me nte<ned in a system of records designated as NRC 16 and desenbed et 46 Federal Regester 46717 (September 21.1961L

1. AUTHORITY. Sectron 107 and 16114) of the Atom.c Energy Act of 1954. as amended 442 U.S.C. 2137 and 2201 till.

2 PRINCIP AL PURPOSES. The informenon witi be cotlected and evaluated for determeneng licenomg eligib.fity and to generate statistical data and reports on 1. censing actione.

3. ROUTINE USES. Information entered on thre form may be used to: les determine of the individual meets the requ.remente of to CFR Part 55 to be issued en operetoie license; ibi provide reseeechere with information for statistical evaluations refeted to selection treming and en eminatiori of f ecatety operatore: tel provide f acility management with sufficeent informatson to enroll the indaviduals in the licensed operator requalification program: (d) provide for enemination and testing rnetonal and obtain reeutte from contractore.

4 WHETHER OtSCLOSURE IS M ANOATORY OR VOLUNTARY ANO EFFECT ON INOlVIOU AL OF NOT PROVIDING INFORM ATION is voluntary. However, if the information roguented is not provided. NRC well not t>e able to evoluete whether the opptecatsort meets the requeeemente of 10 CFR Part 56.

5. SYSTEMS M AN AGERS ANO AOORESSES.

Regional Adtwwstrator. Ragson i Regioned Admsrustrator. Region 11 U S. Nucteer ReguLetory Commess.on U.S. Nuclear Regulatory Commessen 631 Pats Avenue 101 Marietta Street. Su.te 2300 Attente, GA JE23 King of Pruss.a. P A 19406 Regonal Admostrator, Regen IV Reg.onal Admwwstrator, Regeon V Regenas Adm.arstrator, Reg.on eli U S. Nucteer Regulatory Commessen U.S. Nuc6 ear Regutatory Commessen U.S. Nucteer Requtatory Commessaon 611 Avon Pters Onve. Sv.te 1000 1450 Maria Lane. Su.ie 210 793 Roosevest Road Art.ngton. TX Not t wasnut Cseen. CA 94536 Glen Ovn. it 60137

e a' ' GaW me u. a. NUCLEAR REULATORY COMMieslON '"'*"$$d"tj *,'Ec,888** * #* " ""**'"

MU PERSONAL QUALIFICATIONS STATEMENT - LICENSEE

t. APPUCast?8 fuba seAAst f6ast. Augammune, s. TYPE Of ApuCAftess t r asumsman1muum 1.te0T l 8. ASAPPUCAftose 8. WANSA AeQuesitD

- M 99 85tWWJ A00A555 OR APO esuessen 1-COLO l-piAsT essumge scem,,,e

.- -8.=se0 8 .as.

Off ISTAft itP COD 8 t. 908efWAL 3 TDaA0 8-ausentrv i l - - -

4.WPGAA04 e_ormen 1 CfflEsseamp 1 SiRTM Daft 8. toukTW MONTm -

OAv vtA n

~

D. OftetA teammsit ' l l l S. TYpt OP U088s00 APPueo P0. 4. Patytout utesspel seeLD

^"

eL OPemATOA a 00CagT asunseca , , , , D. UCasses NutdGGR _ "#1 4. PAOUTV DOCKET feuestia t.80sa0A OPERA 708 W l l l S. LadrTE SA0 es p. Aar 8esidert l l . l, i i

7. esAMG 08 APPUCAarra easPLovt. g CumaeerT POerftess AT PAceUTV

e. PyueT SUPlaeNT9e00NT L AuluuAny unsrf optaAT0a/

A00ml&S

~

D. AS$1STANT PLANT SUPWhestT8N008(7 NAf

'a' nam 'eu4680 Aofff0A; on a $mPT SUPtaVISO.

~

City TAft DP Coot d STAFF EP8088'ata g of g g w ,-

~

e SmFT TECHessCAL A0vt$oa/SmFT tesGasett.

O haut o8 APPUCANTS PACluTV F Lt 00 Cati e spe$TaWCTO.

. .t.se0m Co 9 A00tiloNAL f ACluTV DocatTS fafWh uRE Lgw4WB, retRA70..,180LRo0

] > CONTaot nooW optaA?0m 11 80uCAftoms a mGM SLs*004 e WAJoe aatAign of $7ucy of,T,*g pr% l0 Ga Oot i ,,esed a voCAftoNAtiftCHeseCAL o,"UM** Y,g cN,N o GaA0uAft thG*E t**G '**8' tvrt op taaseamG vas seo am *** *] acenes s GED toutv&LINCY l o-seoset neo orwea 1-Ctaf1FICATE o muassia op vtAas 2. A5&oCAM o* COLLEGE 1-8ACMELoa I4-MASTla t-ooCtomat

12. TR A6aesseG l 13 EXPlatf NCE

. .oNr,e ANo vu. . .eu . t.

I. .o.ef. A=0 vue l.,.eu..tal o' =0.aas i.., i e i o wu s l , , , ,a i a 1 3 tsayy 1-seuCL,EAa

1. Casse eersu Powta PLANT Pute0AMENTALS l l l l i.ao 3-Ptaaet systaus l l l l2-toowiPPwo CLAllmoosa l l l l 3- twS/PPwS oestavatiose l l l l 4-tas, Caw 3-ortmarseG PRACTICE l l l S.oTMta f5cer4#

Ctwtact acou optilAfioses ON smPT l l g

[

Fo&O'.

$sadutafon OrtaatiseG ta=Amses h, 4-ortaA70 7-guptavigoa S.ahoulAfoe seAAstill

.. ,tA=rir...

vt1 ho 9-orMEa #5eseWre

%,  % ,m, COMMlaCAAL MuCLEAR (Men,smo Asam.ga/ fast fl.eerse

_muCToa r oPtaArea ,t ,,

4-lao eseSimucT10m l tt-Semio81 OPlaATon eteensees i tiraA ,ta.o.; o,e i.e n l l l l n -smn suPtsivisoa ,t ,

.. at ou Au.eCArio.e l l l l n-iT A .,imn f.eG eum ,-,

r-or ta .s +,

l l l l ... Aus ,touip ,.o.uct sto, oPtaaroe I  ! 1 l ,,- ,u ,sr...

I 1 l l . . o rm ,s,-.,,,

I i l i l I I I

- 1 I I I le F AC&UTV Opta Arom taAsmenG raoGaau o Gna0vArt os seepo ACCatDef t? o*enarca e Caersito om Nec sw= ele r senAAAfiose 8ACsurv CEPT 1**

raamiseG PaoGaam AT10se"1 om esaC APreovto $8MULATIo8e FAQUTV 14 u$40 tes TMt oPtaAfon fpAssamG PeoGaAAA l'll l l eso lvas l lseo 4 fon atsofwALS o8stv seovat Ortmaf to f ACsuTV

a WWITIsis TTfL4 peORs TO GL PAOUTV a. Dutist

.,4 esaseggsps sesses> sne amm esmas e anna ses se emammagpr

! u nas seem an. essmasanen se enseinat smaammanesi er encar v ucenese e anace.so.

I Anv tems guesment er asuuumaan en een assumpet, susueng snessimenebeney to empset to esud and crevene eenceers tee I esume unge suume of guns, put en m se emasuuun se esmuseusse a sus se emners. e amo awswee so IsAC es asseus ses sames of sessummese e sny emensvee ter uns se penmug l 8WWW4 6 5 6

, i 1 seossarune.neeuc ar I oats i

&0WIWW aus sus sesW MhW sammes suseeM M ear suas mm en esu m Se W Mcessay Osmuserssesmer N Ishe85W450asse empus a passen seaner h,asnoniesesumasasssur__itener aumense ebene se sist sie suses Depener ensusuu es Tee 10. eyes,

. e esas Camunser of Wasus, W Pye,M,.

of se a SulSe h a em muassuseslug m eegeaosessert.

. I esosiatune-reamasse Coonom. aron i cart senarvat-seamoa nnamaoement noenesentativi on sits ' cara l

' e. e0Algesat esthv. e suusy sus su samus ammus semanse suas as assaues _ ---e e sus eyes,spesa seen assummou nous a son Ih as sensus e, emmemn to es u et to Cpet go mas eue seem sums em Wasps 8tatemp aussung _ _

. ens assusy unser peup, se yeary e peu ou senessionen et se ensunere sus amesusupus e ete was ensure.

a f sseanafunt-feassesG Co0Acusaf 0A 3 oafI siGasafung.senson wassaGeeseNT atratsamf aftyt oss slit I Cait POft NRC USE

• • 'veaeen e. e asas ,

watts naouetwents

~

Ottoos, GaasefLD s' ot %" 0 8 '

- -1... - r.m .u a r a n u,1 ,,1_ 0045 asof utt? etouestaatNts s.,,, s e a. s ..mt.t. ....

,,. l

[ SUeie#UTV l

Oftet) seat penas a seen l

l.

• . -ENCLOSURE 2 i

SUMMARY

OF CHANGES TO NRC FORM 398 Item 4.a -

Moved "New" to below " Hot" and " Cold".'

Item 4.f - Combined " Oral" an'd " Simulator" into " Operating". -

Item 5.d - Deleted " Instructor Certification",

i Iter,i 14 - Added a new item " Facility Operator Training Program" and incorporated under this item the INPO l accreditation block (originally under Training);

added a block for NRC approved or NRC Fom 474

~

certified simulation facility.

i 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.

4 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.

l 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 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".

,-----,..,yw...--,3

,e, .m-,--#.m., -,-,---,w-,, . , , - - ,-

~~ '

ENCLOSURE 3 PERSONAL a ALIFICATIONS STATEMENT - LICENSEE NRC FORM 398 (REV 4/87)

NEW APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 COMPLETELY, FOLLOWING INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING, AND EXPERIENCE THAT APPLICANT HAS RECEIVED UP TO THE DATE OF THIS APPLICATION (NOTE EXCEPTION:

SEE ITEM 14).

~

RENEWAL, UPGRADE, MULTI-UNIT AND REAPPLICATION APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 EXCEPT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE RECEIVED SINCE LAST APPLICATION (NOTE EXCEPTION: SEE ITEM 14).

A SEPARATE NRC FORM 398 FORM MUST BE SUBMITTED EACH TIME AN APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.

1 ITEM 1 -

FULL NAME AND CURRENT ADDRESS.

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

, ITEM 3 - DATE OF .11RTH.

, ITEM 4 - TYPE OF APPLICATION.

"X" appilcable boxes l

i 1-Hot - Applying for a license at

.a plant that has achieved initial criticality. This should <

be completed for each appilcation.

l 2-Cold - Applying for a license at e plant that has not achieved l

inittel criticality. This should be completed for each appilcation.

a. New - Applying for the first time st this facility OR If previously l 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 l

' UP TO THE DATE OF THIS APPLICATION.

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

l I

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 NUST 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 t APPLICATION.

l THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

e. Reappilcation - Previously took a licensing exam and was denied a license and is now reapplying for that same type of Ilcense 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 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.

3 1-First - If denied a license for the first time, the applicant must wait two months from the date of dental 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 reapplying for a license.

3-Third - If denied a license for

, the third time, the appilcant must wait two years from the date of dental 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 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 exam.

! 3-Eligibility - To request a walver on i eligibility requirements.

i 4-Other - To request any other walver,

. I.e., medical.

1 ITEM 5 -

TYPE OF LICENSE APPLIED FOR

a. Operator - Applying for en operator license.

b. Senior Operator - Applying for a senior operator I license.

c. Limited SRO - Applying for a i lmited senior l operator license (e.g. fuel handler).

l l

l ITEM 6 -

PREVIOUS LICENSE (S) HELD l

i

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

certificate).

l '

l a. Docket Number - Docket number assigned for I previous license (s) held j (55-XXXXX). Indicate i f this license

' was for RO or SRO. If this was for l

~ - -

v.---,xwwng,,w--,--g,, ,,n,www- ,,,--e .- a,w__,. .-,-.,,,.---,-.-ne~~-- --

Instructor Cortificotten er Llottod Senior Operator, please write in.

If a denial letter was issued, a docket number was assigned and should be indicated i n 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 license expiration.

If several renewals have occurred, IIst only latest expiration date.

d. Facility Docket No. -

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

Note: If previously held license / instructor certification at a training center, simulator, etc.,

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

ITEM 7 -

NAME OF APPLICANT'S EMPLOYER Name and address of current employer.

ITEM 8 -

NAME OF APPLICANT'S FACILITY Name and docket number (50-XXX) of facility where applying for a license.

ITEM 9 -

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

l ITEM 10 -

CURRENT POSITION AT FACILITY

a. Plant Superintendent -

Note license type 11 required l

by position.

b. Assistant Plant Superintendent -

Note license type if required by position.

c. Shift Supervisor -

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

d. Staff Engineer -

Note license type if required by position.

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

f. Instructor -

Note license type If required by position.

y -

3--, ,- .- - -

. . = .-

r , ,

g. Sonier Csntrol Roco Operator - Position requires current senior

. Ilconse 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. Auxillary Unit Operator / Trainee /

Turbine Building /

Equipment Operator (non-11 censed 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 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 college successfully completed.

(Freshman = 0 to 1 year Sophomores 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-l Engineering - Fleid of engineering majored l int number of years, ands I

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, sppilcable to the operation of a j

r i ptw0r plant. Includo cuch progrces os nuciocr p: wor 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.

ITEM 12 -

TRAINING - Training is Indicated in weeks 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 i

counted under Experience, Item 13.

I 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 coverinD nuclear pouer plant systems and system and component malfunctions.

Observation - Planned systematic observation training on accessible plant equipment.

L - _ _ _ _ _. _ _ _ . _ _ . _ .._...__._. _ _._ . _ _

I .

3-Oporoting Prcctico - Training in cp0 rating practices in the control room for which the f candidate will license and at a plant referenced simulator if one is available.

Control Room Operations -

Observation of the operating practices and the operation of nuclear power plant from the central control room. Not Ilconse 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 preoperational testing program.

Actual time assigned to the

{ operating shift should be counted in 12.5 below.

Simuistor Operations (Includes Classroom) -

Practice in manipulating 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 than two simuistors specify the two most recent only.

Startup Certification Completed - "X" Yes or No. (Notes For 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 Manipulations: - Number of actual reactivity manipulations in which the appilcant was involved broken down by plant and simulator. (Details should be provided in Comments, Item 17.)

4-SRO Instruction -

Instruction in the duties of a senior operator.

, --8

= .

5-Entre Person on Shift - Must be e alnlaum of three months on shift performing the octual k

• 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 es operating experience.

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

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

Include number of research reactor startups, if performed.

ITEM 13 -

EXPERIENCE - Experlence is indicated in months.

For each position held, list the month / year to cover the period you were quellfled for that position. The number of months must reflect the time spent actually exercising the respon-sibl11tles of that position.

Item 14 should be completed for each position held. DO NOT DOUBLE COUNT TIME. If there were overlapping duties, the number of months should reflect the proportlenete 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.

NAVY - Military nuclear power experience should be ilsted in I-5.

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

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

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

i

, 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 certlfled 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 11 more space is needed.

ITEM 17 - COMMENTS - This space should be used to complete Information from previous items or clarlfication for other items on the appilcation 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 renews! 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, walvers may be granted on a case basis if the original medical evaluation was per formed within one year. If walver is requested, Item 4.f.4 should be marked.

o . -

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 detailed 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-Ehlft Supervisor (Licensed) - Must hold or have held valid NRC senior operator license.

13-Staff / Shift Engineer (Licensed) - Must be at the feel 1Ity and involved in the day-to-day plant operational (engineering) staff work.

14-Aux./ Equip. (Nonlleensed)

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 detalled enough to allow evaluation.

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

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

11 - ,

ITEM 19 - SIGNATURES REQUIRED Any false statement or omaission in this document, including attachments, cay be subject to civil and criminal sanctions. -

e. Date end 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 appilcant's employer.

b. Date and signature of Tralning Coordinator AND Senior Management Representative on Site certifying, under penalty of perjury, that oppilcant has successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant to 10CFR551 and that the oppilcant has a need for this license to perform assigned duties. Also certifies that facility ulli be evallable 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 oppilcent 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. ,_

i l

l 1

I i

i f

- - , _ , .-_ - -- - -.-_ _ _ _.-- _ .._ - _