ML20217P195

Forwards Revised NRC Form-398, Personal Qualifications Statement Licensee, & Form-396, Certification of Medical Exam by Facility Licensee. Addendum Instructions for Completing Form Are Provided,Due to Error on Form-398

ML20217P195
Person / Time
Site:	Calvert Cliffs
Issue date:	04/02/1998
From:	Conte R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Hornick J BALTIMORE GAS & ELECTRIC CO.
References
NUDOCS 9804100021
Download: ML20217P195 (10)

Text

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W b ,k APR 2' 1998 Mr. John Hornick Supervisor . Initial Training Baltimore Gas & Electric Co.

1650 Calvert Cliffs Parkway Lusby, Marylandi20657 Gentlemen:'  !

SUBJECT:

REVISED NRC FORMS 398 and 396 Enclosed is a copy of the revised forms: NRC Form-398, Personal Qualifications Statement '

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- - Licenses' (Enclosure 1), and NRC Form-396, Certification of Medical Examination by Facility Licensee (Enclosure 2). Due to error on the instructions for Form 398, addendum instructions for completing the form are provided as Enclosure 3 to this letter. You should

. use these forms immediately for any new applications or license renewals that you are

" sending to the NRC.

- Enclosure 4 provides a summary of the detailed changes for these forms. On Form 398, you shoJld note that applicants are now required to provide evidence on the significant control manipulations performed as trainees at the facility for which the license is being

- sought. ;On this matter, you should refer to NRC Information Notice No. 97-67, dated )

. August 21,1997.

On Form 396, the applicable guidance used in making the medical determinations needs to

! be indicated. Also, be advised that the NRC staff has recently approved Revision 3 of Regulatory Guide 1.134, " Medica Evaluation of Licensed Personnel at Nuclear Power

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,' . Plants," which endorses ANSI /ANS-3.4-1996," Medical Certification and Monitoring of Personnel Requiring Operator Licenses for Nuclear Power Plants." A notice in the Federal J Register will be out. shortly.

Further, you should keep a copy of. Enclosure 3 with the Form 398 until new forms are printed and distributed. Your office can obtain. additional copies of both forms by L contacting Beverly Martin by telephone on 301-415-5877or by writing to her, U.S.

Nuclear Regulatory Commission, Office of the Chief Information Officer, Mail Stop T-6-F-33, Washington, D.C. 20555-0001,or e-mail BAM1 @NRC. gov.- \ j

\ j 9804100021 990402 $

PDR ADOCK 05000317 l?

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l Mr. John Hornick j If you have any questions regarding these forms, please contact Virgil Curley at 610-337-5379 or by e-mail VNC@NRC. gov.

Sincerely, I

/-Cfd Richa d J. Conte, Chief I Operator Licensing and Human Performance Branch ]

Division of Reactor Safety Docket Nos. 50-317 and 50-318 i I

Enclosure 1: NRC Form-398 - Personal Qualifications Statement - Licensee Enclosure 2: NRC Form-396 - Certification of Medical Examination by Facility Licensee Enclosure 3: Addendum Instructions for NRC Form-398 Enclosure 4: Description of Changes to NRC Forms-398 and 396 cc w/ enclosures:

P. L. Katz, Plant General Manager PUBLIC i

l bec w/ enclosures:

l OL Facility File j l

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DOCUMENT NAME: A:\ forms.cc T3 receive a copy of this document. Indicate in the box: "C" = Copy without attachment / enclosure "E" = Copy with attachment / enclosure "N" = No I copyf 0FFICE RI/DRS . l RI/DRS t/ l / l l l NAME Curley19 Conte / u DATE 03/31/98 Sa1 / /98 03/ /98 03/ /98 03/ /98 OFFICIAL RECORD COPY

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ENCLOSURE 3 ADDENDUM INSTRUCTION TO NRC FORM 398 Applies to the Instructions for item 4.g, on the " Type of Application":

g. DATE PASSED GENERIC FUNDAMENTALS EXAM SECTION (GFES)

The last sentence of 4.g states: "This does not include instructor certification examinations or requalification examinations".

]

This statement is in error and is not in accordance with Interim Rev. 8, ES-205, section B, third paragraph, which states as follows:

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" Applicants do not need to take the GFE (nor obtain a waiver) if they were i previously issued an RO or SRO license or an instructor certification i

[ underline added] based on a site specific written examination (on the same )

type of facility) that was administered between February 1982 and i November 1989 and included the material covered by the GFE. Applicants who were issued a license before 1982, will have to take the examination or apply for a waiver in accordance with ES-204.

The last sentence of 4.g should read, "This does not include reaualification examinations."

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I ENCLOSURE 4 I CHANGES TO NRC FORMS 398 AND 396 NRC Form item Desr,ription of Changes Number Number

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398 4.g /,ee Enclosure 3 398 13 Instruction Sheet: All new applications must provide evidence in accordance with 10 CFR 55.31(b) that the applicant, as a trainee, has successful!y manipulated the controls of the facility for which a license is sought. This section was changed to read as follows:

"At a minimum, five significant control manipulations must be performed which affect reactivity or power level under item 1

13.3c. list the five sianificant control manioulations in item i

1. 17." {

l 398 18 Instruction Sheet - changed to read: "NRC Form-396, Certification of Medical Examination by Facility licensee must accompany this application unless a waiver of the medical examination is beina reauested.

398 NA Form: The OMB expiration date is now 10/31/2000 In the OMB block the following was added: "If an information )

l collection does not disclav a currently valid OMB control i number, the NRC may not conduct or sconsor, and a personjg l not reauired to resoond to the information collection".

398 NA Form and Instructions: Top and Bottom left-hand side have date changes to 10-1997.

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NRC Form item Description of Changes Number Number 396 Item A Medical Exam Information - statement regarding safeguards and fitness for duty requirements has been moved from item B to be included with the statement under A - Medical Exam Information as noted below:

"This is to certify that the above named applicant for an operator / senior operator license has been examined by a physician and that the anolicant has been found to meet the safeauards and fitness for duty reauirements for licensed operators at this facility."

Item A Below the physician name,...... line, the word " physical" has been added:

" Based on the results of the ohvsical examination, including...."

In this same paragraph it states as follows: "I certify that in reaching this determination, the guidance contained in ANSI /ANS 3.4-1996. or ANSI /ANS 3./ 1983 was used, item B NONMEDICAL CERTIFICATION (old form) has been changed to: B - CERTIFICATION (new form) 396 NA Top and Bottom left-hand side of the form have date changes to 3-1998 1 1

396 NA Top right corner - OMB expiration date changed to : I 12/31/1999 k

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INSTRUCTIONS FOR COMPLETING NRC FORC 398, PERSONAL QUALIFICATION STATEMENT-LICENSEE TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED

4. TYPE OF APPLICATION O. NEW 7" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATION. NOTE: SEE ITEM 12 -THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "NEW."

FOR 4 b THROUGH 4 e. COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION. NOTE: SEE ITEM 12 -THERE IS AN EXCEPTION.

b. RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE.

c. UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO.

d. MULTI-UNIT "X"IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CURRENT LICENSE TO ADD AN ADDITIONAL UNIT.

o. REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

f. WAIVER REQUESTED "X" THE APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

g. DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES) THIS IS NOT APPLICABLE TO RESEARCH REACTORS OR LICENSES LIMITED TO FUEL HANDLING. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINATION SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FESRUARY 1,1982, WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES MQllNCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

11. EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAUTECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREA (S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAtJTECHNICAL EDUCATION, INCLUDING PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC. INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED. IF ADDITIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17).

13. FACILITY OPERATOR TRAINING PROGRAM - CHECK THE APPROPRIATE BOX IN ITEMS 12.a AND 12.b. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD.

NOTE: IF "YES" IS CHECKED IN BOTH ITEMS 12.a AND 12 b, THEN ITEMS 13 (TRAINING),14 (EXPERIENCE), AND 15 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED, WITH THE EXCEPTION OF BLOCK 13 3 c. ALL NEW APPLICATIONS (fTEM 4 a) MUST INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS WHICH AFFECT REACTIVITY OR POWER LEVEL UNDER ITEM 13.3 c.

93. TRAINING - ALL NEW APPLICATIONS MUST PROVIDE EVIDENCE THAT THE APPLICANT, AS A TRAINEE HAS SUCCESSFULLY MANIPULATED THE CONTROLS OF THE FACILITY FOR WHICH A LICENSE IS SOUGHT. AT A MINIMUM, FIVE SIGNIFICANT CONTROL i

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MANIPULATIONS MUST DE PERFORMED WHICH AFFECT REACTMTY OR POWER LEVEL UNDER ITEM 13.3 A IN ACCORDANCE WITH 10 CFR 55.31(b), LIST THE FIVE SIGNIFICANT CONTROL MANIPULATIONS IN ITEM 17, l ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM 13.6. PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING FOR CLASSROOM OR SIMULATOR TIME UNDER ITEMS 13.1.13.2, OR 13.3.

14. EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REOUIRED. FOR EACH POSITION HELD, COMPLETE ITEM 15. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES, THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASTE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

15. EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION IF MORE SPACE IS NEEDED,USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATlON.

16. FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT FACILITY REQUALIFICATION EXAMINATION.

17. COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPLICATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICATION.

18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION UNLESS A WAIVER OF THE MEDICAL EXAMINATION IS BEING REQUESTED.

19. SIGNATURES - SIGN AND DATE ITEM 19 a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 AND 396 (ORIGINAL AND TWO COPIES EACH) TO THE APPROPRLATE REGIONAL ADMINISTRATOR. (SEE PEVERSE SIDE FOR ADDRESSES OF REGIONAL ADMINISTRATORS AND FOR THE PRIVACY ACT STATEMENT.)

NRC FORM 396 (S1997)

INSTRUCTIONS FOR COMPLETING NRC FORM 398, PERSONAL QUALIFICATION STATECENT-LICENSEE TO REMAIN VAlfD, THIS FORM MUST NOT BE ALTERED

! 4. TYPE OF APPLICATION

a. NEW "X" IF YOU ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATION. NOTE: SEE ITEM 12 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "NEW."

FOR 4 b THROUGH 4 e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION. NOTE: SEE ITEM 12 THERE IS AN EXCEPTION.

b. RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE.

c. UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO.

d. MULTI-UNIT "X"IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CURRENT LICENSE TO ADD AN ADDITIONAL UNIT.

e. REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

f. WAIVER REQUESTED "X" THE APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

g. DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES) - THIS IS NOT APPLICABLE TO RESEARCH REACTORS OR LICENSES LIMITED TO FUEL HANDLING. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINATION SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982, WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES MQIINCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

M. EDUCATION INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREA (S)OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDING PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC. INDICATE ThE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED IF ADDITIONAL SPACE IS NEEDED, CONTINUE UNDER COMMF.NTS (ITEM 17).

13. FACILITY OPERATOR TRAINING PROGRAM - CHECK THE APPROPRIATE BOX IN ITEMS 12.a AND 12.b. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD.

NOTE: IF "YES" IS CHECKED IN BOTH ITEMS 12.a AND 12 b, THEN ITEMS 13 (TRAINING),14 (EXPERIENCE), AND 15 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED,WITH THE EXCEPTION OF BLOCK 13 3 e ALL NEW APPLICATIONS (ITEM 4 a) MUST INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS WHICH AFFECT REACTIVITY OR POWER LEVEL UNDER ITEM l 13.3 c.

13. TRAINING - ALL NEW APPLICATIONS MUST PROVIDE EVIDENCE THAT THE APPLICANT, AS A MAINEE, HAS SUCCESSFULLY MANIPULATED THE CONTROLS OF THE FACILITY FOR WHICH A LICENSE IS SOUGHT. AT A MINIMUM, FIVE SIGNIFICANT CONTROL MANIPULATIONS MUST BE PERFORMED WHICH AFFECT REACTMTY OR POWER LEVEL UNDER ITEM 13.3 c. IN ACCORDANCE WITH 10 CFR 55.31(b), LIST THE FIVE SIGNIFICANT CONTROL MANIPULATIONS IN ITEM 17.

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM 13 6. PLEASE DO NOT "DOUSLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING FOR CLASSROOM OR SIMULATOR TIME UNDER ITEMS 131,13 2, OR 13.3.

14. EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR EACH POSITION HELD, COMPLETE ITEM 15. DO NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES, THE MONTHS SHOULO REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT LRE IN THAT TIME PERIOD.

15. EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IT NAT POSITION. IF MORE SPACE IS NEEDED,USE COMMENTS (ITEM 17), OR (F NECESSARY, ATTACH ADDITIONAL INFORMATION.

16. FOR RENEWALS ONLY - (1) ENTt9 %i ADPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE IF "lRST RENEWAL. (2) ENTER DATL MJD RESULT OF MOST RECENT FACILITY REQUALIFICATION EXAMINATION.

17. COMMENTS USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPLICATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICATION.

18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION UNLESS A WAIVER OF THE MEDICAL EXAMINATION 'S BEING REQUESTED.

19. SIGNATURES - SIGN AND DATE ITEM 19 a OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE. l DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 AND 396 (ORIGINAL AND TWO COPIES EACH) TO THE APPROPRIATE REGIONAL ADMINISTRATOR. (SEE REVERSE SIDE FOR ADDRESSES OF REGIONAL ADMINISTRATORS AND FOR THE PRIVACY ACT STATEMENT.) l NRC FORM 396 (101997)

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ADDRESSES OF REGIONAL ADMINISTRATORS in accordance with 10 CFR 55.5, Communications, this form shall be submitted to the NRC as follows: BY MAIL ADDRES REGIONAL ADMINISTRATOR, REGION I REGIONAL ADMINISTRATOR, REGION 11 U. S. NUCLEAR REGULATORY COMMISSION REGIONAL ADMIN'STRATOR, REGION lli 475 ALLENDALE ROAD U.S. NUCLEAR REGULATORY COMMISSION ATLANTA FEDERAL CENTER U.S. NUCLEAR REGULATORY COMMISSION KING OF PRUSSIA. PA 19406-1415 61 FORSYTH STREET S.W., SUITE 23T85 801 WARRENVILLE ROAD j ATLANTA, GA 30303-$415 LISLE. IL 60532-4351 j

REGIONAL ADMINISTRATOR,REGIONIV U. S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION NON-POWER 611 RYAN PLAZA DRIVE, SUITE 400 . OPERATOR LICENSING BRANCH, HQ ARLINGTON, TX 76011-8064 DIVISION OF REACTOR CONTROLS AND U.S. NUCLEAR REGULATORY COMMISSION HUMAN FACTORS NON-POWER REACTORS AND DECOMMISSIONING WASHINGTON, DC 20555-0001 PROJECT DIRECTORATE HQ DIVISION OF REACTOR PRdGRAM MANAGEMENT WASHINGTON DC 20555-0001 PRIVACY ACT STATEMENT supply information to the v S.), Nuclear Regulatory Commission on NRC Form 398. This(inf em of Records designated as -

NRC 16 and desenbod at 58 FederalRegrster 36465 (July 7,1993), or the most recent Federal Repster Washington, D.C."R! publication of Systems of Records Notees" that is available at the NRC Public Document Room, publication of the Gelman Building, Lower Level,2120 L Street NW,

1. AUTHORITY, 42 U.S.C. 2137 and 2201 (1)(1988).

l 2.

PRINCIPAL on PURPOSES.

licensing actions. The information will be collected and evaluated for determining licensing eligibili

3. ROUTINE USES. Information entered on this form may be used to:

i (a determine if the individual meets the requirements of 10 CFR Part 55 to be et sued an operator's limnse; (b) provide researchers with information for s)tatistcal evaluations rel operators; (c) provide facility management with sufficient information to enroll you in the licensed operator requalification procr t.xamination and testing matenal and obtain results from contractors. Information may also be disclosed to appropnate, ,

Federal Sta al, or Foreign oflaw. In addition, information may also be disclosed in the course of an administ to their inquiry made at your request, or to NRC-paid experts, consultants, and others under contract with the NRC, on a

4. .

WHETHER b 10 of voluntary.

CFR Part 55.

DISCLOSURE However, IS MANDATORY if the information requested is not OR VOLUNTARY provided, NRC will not AND be ableEFFECT to evaluateON INDIVID whether the a 6.

Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001 l

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MRC FORM 308 U.S. NUCLEAR REGULATORY COMMISSON APPDM SYOme: WC,31084080 EMPIRES: 1Gf31/3000 DATE RECEIVED N Estimated tier.mn. per lo wilh thee Wannehon mm mi (To be comphed by MRC) 10 CF2 66.31. 66 36. request i hour. NR requres rWormaban to onene that 66 47, and 66.67 applicm.16eAioenese.s,.

.emin ons. F ord meet et_.the reguraments for,tekrig reacsor opermeer PERSONAL QUALIFICATION STATEMENT-LICENSEE informanon and Re=nN Monstemer71@ 'n ann N-*

Commies.on. . DC 20b6641001 and to the

.semene

- io i.nsT4 r33x u.S P part -*=m (31 ). Omco of Meingement and Oudget.Westwusart DC . r en rearmenon ~a=*m dose not desemy TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED e cunerervendIlMb oorwol number, to NRC not conduct or sponsor, and e oorson a not reemed to respond to. Wie ~*='*m )

1. APPLICANT'S FULL NAME (Lest, First, Middle) AND ADORESS (includeZIP Code) 4. TYPE OF APPUCATION (Clieck applicable bonesj l HOT l l COLD

e. NEW l f. WAlVER REQUESTED (Jusrf& on Reveres) j

b. RENEWAL 1. WRITTE N (Categoryl

c. UPGRADE _

0 '#

d. MULTI-UNIT (AMEND TO

_ INCLUDE ADDITIONAL UNIT) _

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e. REAPPLICATON _

1 - FIRST _

2. CITIZENSHIP 3. SIRTH DATE 2 SECOND 6 OTHER

e. UNITED STATES MON DAV YEAR

_ 3 + THIRD UND ME TA INATON

b. OTHERISoeci&) SECTION tlF APPLICABLE) l l l l l

5. TYPE OF LICENSE APPUED FOR 6. PREVIOUS UCENSEIS) HELD

e. OPERATOR e. DOCKET NUMBER RO sRo b. UCENSE NUMBER c [AmN DAM , d. FACILITY DOCKET NUMBER

, b. SENIOR OPERATOR l l I

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c. UMITED SRO te g, fuel Hendner)

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7. NAASE AND ADORESS OF APPUCANT'S EASPLOYER (includeZIPCodel 10. CURRENT POSITION AT FAC8UTY

e. PLANT SUPERINTENDENT L AUXILIARYUNITOPER-ATOR/TRAJNEE/TURSGNE

b. AS$1STANT PLANT SUPERINTENDENT BUILDINGKQUIPMENT OPERATOR (NON UCENS.

c. SHIFT SUPERVISOR

- EO OWRATOR) j d. STAFF ENGINEER

j. OTHER (Spec #yl C. NARAE OF APPUCANT'S FACIUTY e. SHIFT TECHNICAL ADVISOfVSHIFT ENGINEER l FACluTY DOCKET NUMBER

,  %,,, f. INSTRUCTOR S. ADOfTIONAL FACIUTY DOCKETS (Mutts-unst Lacenses, -

g. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION

a. HIGH SCleOOL e. MAJOR AREA (S) OF STUOV o E, Un' DEGREE COOGS d. VOCATIONAL / TECHNICAL Y" "R o G3ADUATE ENGINEERING (FtELDS) am.c NEE pefe ) N* ^*N " "

1 0 NONE l GED EQUIVALENCY 1 - CERTIFICATE

~ OTHER NO 2 ASSOCIATE i

3 BACHELOR

! th NUMeEACF 4 MASTER I S NL 6 - DOCTORAL

12. FACIUTY OPERATOR TRAINING PIIOGRAAA

e. INPO ACCREDITED OPERATOR TRA9eNG b. CERTFIED ION NRC FORM 474 *SAMUtADON FACEITY PROGRAM THAT 18 SAsED WPON A $Y$TEMs YES NO carnArgw iOR NRC APPROVEDlWMULATION FACIUTYis YES NO APPROACH TO TRApeNG USED iN THE OPERATOR TRAINING PROGRAM

13. TRAINING (SINCE LAST APPUCATION- SEEINSTRUCTIONS) 14. EKPERIENCE (D0 NOT DOUBLE COUNT-SEE INSTRUCTIONS)

. ixw.m As o YEAR a Nuuso . wom mo vw msuus ,

FHUIA TO OF WEH3 F,i!OM To cP Mar #e 1 - NUCLEAR POWER PLAhff FUNDAMENTALS U 1 RO 2 - PLANT SYSTEMS 3 EOOW/PPWO CLASSROOM 3 + EWS/PPWS O~AE3VATION 4 ERS/CRW 3 - OPERATING PRACTICE *

1. M CONTT.0L ROOM OPERATIONS ON SHIFT SIMULATOR OPERATING (Jactudes CJeseroom)

, 6 OPERATOR SIMULATOR NAMES &c w - r 7t<

g h/ kyyhkrh T SUPERVISOR 8 PLANT STAFF b-  ;; .

8

• A O#***#

EMcEfto l l YES l lNO ,# g e NUMeER s#GNiFicANT CONTROL MANIPULATIONS stMutATon

, $,EM.l);

3

.v p

i[{)>]p[jh COAAMERCIAL NUCLE 4R fJncluding ResearcVTest Reactor) fy' $$hh[pQg;N.'< khf.h '/ 4 t

10 REACTOROPEhATOR(Licen,wd) l 11 SENIOR OPERATOR (s.' en wd/

4 - SRO INSTRUCTION 12 - SHIFT SUPE RVISOR flicensed) g gjYg}RgSHe1 of CONTROL ROOM 13 * $TAFF/ SHIFT ENGINEER flicensed) g T,off Aj0VE 20% POWER 14 OPERATOR (Nonticensed) 4 - REQUAUFICATION 16 PLANT STAFF

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18 OTHER ISpectyl NRC FORM 300 (101907)

3 I. .

-. j is. ExcemmNeEDETAn.S 4L POSITIONTITLE FROM TO b. FACILITY c. DUTIES i

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18. FOR RERWWALS ONLY

b. DATE AND RESULT OF MOST ** '"'"

c. HOURS OPEP.ATED FACILITY: MCENT FACluTY PASS FAIL MOUAllFICATION EXAM

11. COMMENTS LSpecify the item number to which you are elaborating. Attach additional sheets if necessaryJ l

1 J. NRC PORRA 398 CERTIFtCAT90N OF RAE00 CAL EXAAAINATION SY FACRJTY L8CE90SEE,IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

19a. I certify under penalty of perjury that ths information in this document and attachments is true and cormet. I further certdy that I have notdsed my current employer of- (1) all previous employers;(2) any 6 stance where I have been tested by a Health and Human Services (HHS) Cert fsed Drug Testeng Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results tscoeded the cutoff levels estabhshed pursuant to 10 CFR Part 26; (3) any instance where i have been arrested for the sale. use or possession of a controlled substance described in 10 CFR Part 26; and (4) any reasons for removal or revocation of unescorted access et a nuclear facH6ty. I also a Jthorlie the NRC to submit tne results of exavnirtations to my ornployers for use in preparing retra6 rung programs, as necessary.

SIGNATURE-APPLICANT l DATE l CHECK APPUCABLE BOX

b. I certdy that the above named individual has successfuliy corr plated the facalaty licensees requirements to be teensed as an Operator / Senior Operator pursuant to Tstle 10. Code of Federal

-] Regulations, Port $$; and that the individual has a need for an Operator / Senior Operator license to perform his/her assigned duties and that the facility will be made available for examination.

4 (teo certify under penalty of perju.y thJt the information in this document and attachments is true and correct. l l c. RENEWAL ONLY. I certify that the above named indivutual meets the approved raqualification program twsth exceprsona notedin frem 87) as required by section 60.64 li-1) of 10 CFR 60, and  !

I that he/she has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this documem and '

attachments is true and correct;.

TRAlpf1NG COORDINATOR SENIOR RAANAGERAENT REPRESENTATIVE ON SITE PRINTED OR TYPED NAME AND TITLE PRINTED OR TYPED NAME AND TITLE SIGNATURE SIGNATURE lDATE lDATE .

FOR M N  ;

WAIVER (Check or Complete items, as applicable) l MEETS REQUIREMENTS l l DOES NOT MEET REQUIREMENTS Explain below)  !

URANTED DV WNIED SV CARGORY wr. ADDUAr u na RE G40N HE ADQUANTF RS REGION WRITTEN ,

OPERATING f ELIGlBILITY MEDICAL - SIGNATURE-REVIEWER f lDATE OTHER.

NRC FORM 300 (141gg7) e O

bwio son c- JL NRC FORM 396 U.S. NUCLEAR REGULATORY COMMISSION APPROVED EY OMB: NO 3150-0024 EXPlRES: 12/31/1999 (3-199e) Estsnated burden per response to comply wtth this hforrnauon cotection requei 10 CF R 55 21. 55 23. 15 rrunutes. NRC requires 1his Mformaton to determme that the physcal conditson and 53 25.55 27.55 31 healthof operator Icensees is such that the apphcant would not be 5 xpected to cause 55 33.65 57 opercional errors endangenng the pubic healtn and safety. Fone?d corr nents regardng burden estimate to the information and Records Management Brarch (T 6 F33), U.S. Nuclear RegulatoryComrrussion. Washngton, DC 205550001, and to CERTIFICATION OF MEDICAL EXAMINATION ine esperwor= Reducuan erw oi5040m. Orr= of uanseemeni and Bud 2.t.

Washmgtort DC 20503. If an informaison collection does not display a currently vahd BY FACILITY LICENSEE Ouo corwa number. NRC mey not conduct or sponsor and a person is not requred to respond to, the Mformation conection.

HAME OF APPLICANT FAf,ILITY FACILITY DOCKET NUMBER A. MEDICAL EXAM INFORMATION THtS O TO CERTIFY THAT THE ABOVE NAMED APPUCANT FOR AN OPERATOR / SENIOR OPERATOR UCENSE HAS BEEN EXAMINED BY A PHYSICIAN AND THAT THE APPUCANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS FOR UCENSED OPERATORS AT THfS FACILITY.

PRINTED NAME (of physraan) STATE AND LICENSE NUMBER MOST RECENT MEDICAL E.AAMINATION DATE BASED ON THE RESULTS OF THE PHYSICALEXAMINATION.lNCLUDINGINFORMATIONFURNISHED BY THE APPUCANT.THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE SUCH THAT THE APPUCANT WOULD NOT BE EXPECTED TO CAUSE OPERATIONAL ERRORS ENDANGERING PUBUC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUlOANCE CONTAINED IN ANSUANS 3.41996. ANSUANS 3.4-1983.OR ANSUANS 15.4-1988(N380)WAS FOU.OWEDAS ENDORSEDBY THE APPUCABLE NRC REGULATORY GUIDE. AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC. IF THE GUIDANCE IN THE APPROPRIATE ANSVANS DCCUMENT IS NOT COMPUED WITH, AN ACCEPTABLE ALTERNATTVE METHOD. WHICH HAS BEEN APPROVED BY NRC, WAS USED.

ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. IT IS REQUESTED THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:

1. NO RESTRICTIONS

2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES

3. HEARING AfD BE WORN WHEN PERFORMING LICENSED DLITIES 4 RESTRICTED LICENSE OR EXCEPTION - Provide explanation and attach supporting tr71ical evidence for NRC review.

S. RESTRICTV)N CHANGE FROM PREVIOUS SUBMITTAL - Provide explanation for restricscm change and attach supporting medcal evidence for NRC rewew

6. INFORMATION ONLY PROPOSED WORDING OF RESTRICTION (Sbc2 4 above) GUIDANCE USED IN REACHING THIS DETERMINATION.

ANSI /ANS 3.4 - 1996 ANSUANS 3 4 1983 ANSUANS 15.4 - 1980 (NON-POWER)

OTHER (Specdy)

RELt.TIONSHIP OF RESTRICTK)N TO DISQUALIFYtNG CONDITX)N (Sne#y mecate how nrstroon m# correct the daquaMymg condson)

EXPLANATION FOR RESTRICTION CHANGE (8doch 6 above)

B. CERTIFICATION ANY FALSE STATEMENTOR OMISSIONIN TH'S DOCUMENT, INCLUDING ATTACHMENTS. MAY BE SUBJECT TO CML AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.

PRINTED NAME AND TITLE (Senior Management Reposenta#ve on Site) l SIGNATURE lDATE in accortia~. w with 16 CFR 55.5. Cornmunications, this original form shall be subrn[ttbd to the appropriate NRC omce as follows: BY MAIL ADDRESSED TO:

REGl(*dAL ADMINtSTRATOR REGIONI REGIONAL ADMINISTRATOR. REGION 11 REGIONAL ADMINISTRATOR. REGION 111 U.S. AUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION 47f, ALLENDALE ROAD ATLANTA FEDERAL CENTER 801 WARREfMLLE RD K34G OF PRUSSIA PA 19406-1415 61 FORSYTH STREET. S.W., SUITE 23T85 USLE. IL 60532 4 351 ATLANTA. GA 30303 4415 REG 4ONAL ADMINISTRATOR REGION IV U.S. NUCLEAR REGULATORY COMutSSION NON#OWER U.S. NUCLEAR REGULATORY COMMISSION OPERATOR UCENSING BRANCH, HQ U.S. NUCLEAR REGULATORY COMMISSION 811 RYAN PLAZA DRIVE, SUITE 400 DIVISION OF REACTOR CONTROLS AND NON-POWER REACTORS AND DECOMMISSIONING ARLINGTON.TX 7tiO114064 HUMAN FACTORS PROJECT DIRECTORATE. HQ WASHINGTON, DC 205554001 DfVISION OF REACTOR PROGRAM MANAGEMENT WASHINGTON. DC 20555-0001 NRC FORM 398 (3-1990) PRINTED ON RECYCLED PAPER

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