ML21214A220

OMB 3150-0090, Draft 2022 Collection Renewal, NRC Form 398 Personal Qualification Statement - Licensee - NRC Form 398

ML21214A220
Person / Time
Issue date:	01/27/2022
From:	NRC/NRR/DRO
To:	NRC/OCIO
Shared Package
ML21211A235	List: ML21214A219 ML21214A220 ML22055A052
References
NRC-2021-0151, OMB 3150-0090
Download: ML21214A220 (6)

Text

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 EXPIRES: (MM/DD/YYYY) Date Received NRC FORM 398 (MM-YYYY) (To be completed by NRC)

Estimated burden per response to comply with this mandatory collection request: 2.56 hours6.481481e-4 days <br />0.0156 hours <br />9.259259e-5 weeks <br />2.1308e-5 months <br />. NRC requires this 10 CFR 55.31, 55.33, 55.35, 55.47, 55.53, PERSONAL information to ensure that applicants/licensees meet all the requirements for taking reactor operator examinations.

Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S.

and 55.57. QUALIFICATION Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0090), Attn: Desk Officer for the Nuclear STATEMENT -- LICENSEE Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

1. Last Name 2. First Name 3. Middle Initial Suffix 4. Birth Date: (MM/DD/YYYY) 5. E-mail Address (electronic correspondence option)

6. Address (Number & Street, line 1) 7. Address (Suite, Unit No, etc., line 2) 8. City 9. State 10. Zip Code

11. Type of Application (Check applicable boxes) 12. Deferrals/Excusal/Waivers (See instructions, check all that apply and justify in item 25)

A. NEW E. REAPPLICATION a. DEFERRAL b. EXCUSAL c. WAIVER B. RENEWAL 1 - FIRST DENIAL 1 - ELIGIBILITY 1 - WRITTEN (Category) 1 - WRITTEN (Category)

C. UPGRADE 2 - SECOND DENIAL 2 - EXPERIENCE 2 - OPERATING (Category) 2 - OPERATING (Category)

D. MULTI-UNIT (amend 3 - THIRD DENIAL 3 - MEDICAL to include additional unit) 4 - WITHDRAWAL 4 - OTHER

13. Type of License Applied for: OPERATOR (RO) SENIOR OPERATOR (SRO) LIMITED (LSRO)

14. Docket and Licensing Information Docket Number RO License Number(s) Expiration Date(s) Facility Docket Number (Separate multiple docket numbers by ";")

055 - LSRO 050 SRO 052

15. Name of Applicant's Facility 16. Facility Docket Number 17. Additional Facility Docket Number(s) (Multi-unit Licenses) 050 052

18. Current Position at Facility A. Plant Supervisor/Manager E. Shift Technical Advisor/Shift Engineer I. Trainee B. Assistant Plant Superintendent/Manager F. Instructor J. Non-Licensed Operator C. Shift Supervisor G. Senior Control Room Operator K. Other D. Staff Engineer H. Control Room Operator

19. Education

a. High School b. College DEGREE CODES c. Vocational/Technical Number of

("Highest Degree" obtained) Months Certificate Received Type of Training Number HIGHEST DEGREE 0 - None Graduate Major Area(s) of Study of Years (Use Codes) 1 - Certificate 2 - Associate Yes No GED Equivalency Engineering 3 - Bachelor 4 - Master No Other: 5 - Doctoral Yes No

20. Power Reactor Operator Training Program

a. Has the applicant completed the Operator Training Program accredited by the National Nuclear Accrediting Board? Yes No

b. Is a "Plant-Referenced Simulator" (As defined in 10 CFR 55.4) used in the Operator Training Program? Yes No

21. Training (Since Last Application - See Instructions)

a. Classroom From (MM/YYYY) To (MM/YYYY) No. of Weeks From (MM/YYYY) To (MM/YYYY) No. of Weeks 1 - Nuclear Power Plant Fundamentals d. Extra Person on Shift in Control Room 2 - Plant Systems e. Time on Shift Above 20% Power 3 - Plant Procedures f. Requalification

b. Simulator g. Other (Specify below)

c. SRO Instruction

22. Significant Control Manipulations DESCRIPTION PLANT SIMULATOR DESCRIPTION PLANT SIMULATOR

a. f.

b. g.

c. h.

d. i.

e. j.

NRC FORM 398 (MM-YYYY) Page 1 of 3

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 55.31, 55.33, 55.35, 55.47, 55.53, and 55.57.

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

1. Last Name 2. First Name 3. Middle Initial Suffix Docket Number 055 -

23. Nuclear Experience Details FROM DATE TO DATE POSITION TITLE MONTHS FACILITY DUTIES (MM/YYYY) (MM/YYYY)

24. For Renewals Only

< 100 (LESS THAN) MM/YYYY Result

b. Date and result of last

a. Hours Operated at written comprehensive W PASS FAIL Facility 100 - 1000 requalification exam and

> 1000 (MORE THAN) annual operating test. O PASS FAIL

25. Comments NRC FORM 398 (MM-YYYY) Page 2 of 3

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 55.31, 55.33, 55.35, 55.47, 55.53, and 55.57.

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

1. Last Name 2. First Name 3. Middle Initial Suffix Docket Number 055 -

26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED Yes No

27. Signatures ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

I certify under penalty of perjury that the information in this document and attachments is true and correct in accordance with the instructions. I also authorize 27a.

the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.

Signature and Date - Applicant (Sign in black ink or Digital Signature) 27b. CHECK APPLICABLE BOX(ES) FOR TYPE OF APPLICATION (i.e., check 1 if item 11 a, c, d, or e is checked; check 2 if item 11 b is checked; and check 3 if item 12 a, b, or c is checked.)

1. I certify that: (1) the above named individual has successfully completed the facility licensee's requirements to be licensed as an Operator/Senior Operator pursuant to Title10, Code of Federal Regulations, Part 55; (2) the individual has a need for an Operator/Senior Operator license to perform his/her assigned duties; and (3) the facility will be made available for the examination. I also certify under penalty of perjury that the information in this document and attachments is true and correct in accordance with the instructions.

2. I certify that the above named individual completed the approved requalification program (with the exceptions noted in Item 25) required by section 50.54(i-1) of 10 CFR 50, and that he/she has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this document and attachments is true and correct.

3. I certify that the justifications provided in item 25 support the deferrals, excusals, and/or waivers requested in item 12 for the above named individual. I also certify under penalty of perjury that the information in this document and attachments is true and correct in accordance with the instructions.

Training Coordinator Typed or Printed Name and Title (Training Coordinator)

Signature and Date - Training Coordinator (Sign in black ink or Digital Signature)

Senior Management Representative on Site Typed or Printed Name and Title (Senior Management Representative on Site)

Signature and Date - Senior Management Representative on Site (Sign in black ink or Digital Signature)

FOR NRC USE GRANTED BY DENIED BY Deferral/Excusal/Waiver Requests (Check or Complete items, as applicable) HEADQUARTERS REGION HEADQUARTERS REGION Eligibility Deferral Experience Written Excusal Operating Written Operating Waiver Medical Other Explanation:

MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS Signature and Date (Sign in black ink or Digital Signature)

NRC FORM 398 (MM-YYYY)

Page 3 of 3

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)

How to complete this form: You must complete items 1- 4 and 6-10 and additional items as specified below in the instructions for Block 11, Type of Application. For additional guidance refer to NUREG-1021, "Operator Licensing Examination Standards for Power Reactors," or NUREG-1478, "Non-Power Reactor Operator Licensing Examiner Standards."

5. E-MAIL ADDRESS If you provide an email address, you are electing to receive operator licensing correspondence from the NRC, electronically. If you do not provide an email address, the NRC will correspond using mail to the address you provided in Items 6-10.

11. TYPE OF APPLICATION A. NEW - X if you are a new applicant at this facility (i.e., this is your first request to take the site-specific NRC exam at this facility). Complete items 11-13, 14 (if applicable), and 15-23. If 20.a and 20.b are checked "Yes" then item 21 does not have to be completed.

B. RENEWAL - X if you are renewing a current license. Complete items 11, 14, 18, 20, 21.f and 24; if items 20.a and 20.b are checked Yes, then item 21.f does not have to be completed.

C. UPGRADE - X if you hold an RO license and are applying to upgrade your license to an SRO at the same facility. Complete items 11-18, 21 and 23 relevant to the SRO upgrade. If items 20.a and 20.b are checked "Yes",

then item 21 does not have to be completed.

D. MULTI-UNIT - X if you hold a license at your facility and are applying to amend your current license to an additional unit. Complete items 11-19, and 21-23. Complete item 21 as it applies to unit differences.

E. REAPPLICATION - X if you have previously been denied a license. Complete items 11-19, 21-23, 25.

Indicate whether you are applying after a first denial, second denial, or third denial. Describe, in detail, in items 21 and 25, the additional training completed since the last denial. If you previously withdrew an application, check item 11.E.4.

12. EXCUSAL/DEFERRAL/WAIVER - Refer to NUREG-1021 or NUREG-1478 for additional guidance.

a. DEFERRAL - X if you are requesting a deferral of certain requirements to be able to sit for the scheduled NRC exam. Check which requirements (1 - Eligibility or 2 - Experience) you are requesting deferral of. Identify the specific requirement and indicate the expected completion time for each requirement in item 25.

b. EXCUSAL - X if you are requesting to have a previously passed portion of the NRC exam excused. Indicate which requirements of the requested portion you are requesting excusal from (1 - Written or 2 - Operating) and indicate the category.

For Power Reactors:

For written examination excusals, check box 12.b.1 and enter a category of SSR for the site-specific RO examination or SSS for the site-specific RO and SRO examinations.

For the operating test, the available categories are: administrative topics, control room systems, in-plant systems, simulator operating test, JPM operating test or all of these. Check box 12.b.2 and enter a category of SIM for simulator operating test, JPM for the complete JPM operating test, "SYS" for the systems portion of the JPM operating test (i.e., for an ADMIN-only JPM retake exam), ADM for the administrative portion of the JPM operating test, OTH for another JPM combination not listed here (explain in item 25), or ALL to request excusal from both the simulator operating test and the complete JPM operating test. Provide justification in item 25. Also indicate the expected date of the NRC exam.

For Non-Power Reactors: For written exam excusals, check box 12.b.1 and enter a category of A": to request an excusal of category A, enter a category of B to request an excusal of category B, enter a category of C to request an excusal of category C. For operating test excusals, check box 12.b.2 and enter a category of ALL to request excusal of an operating test. Individual categories of the operating test will not be excused. Provide justification in item 25.

NRC FORM 398 (MM-YYYY)

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)(continued)

c. WAIVER - X if you are requesting a waiver (55.47). For waivers of the written examination and/or operating test, check 12.c.1 and/or 12.c.2 respectively and identify the examination categories using the same designations identified in the instructions for 12.b above. For all waivers, provide additional justification information in item 25.

14. DOCKET AND LICENSING INFORMATION - Provide applicable information for the individual that is applying for the license. Include the individual's docket number if the applicant has previously been assigned a docket number. Leave blank if applicant has not been assigned a docket number. For power reactors, a docket number will be provided after the application is received, via NUREG-1021 Form 2.2-1, List of Applicants. If a license number is provided, then include the associated facility docket number for that license. For facility docket numbers, check the associated type (050 or 052) and then fill in the last 5 digits of the facility docket number.

19. EDUCATION - For college, enter the major area(s) of study, the number of years spent in each major area of study and the highest degree obtained (using degree codes listed on the form). For vocational/technical, enter the number of months for each type of training and whether a certificate was awarded. If additional space is needed, use item 25.

20. POWER REACTOR OPERATOR TRAINING PROGRAM - (This item is not applicable to non-power reactors). Check the appropriate box in items 20.a and 20.b. Checking Yes in item 20.a indicates that you have completed a SAT-based training program that is accredited by the National Nuclear Accrediting Board and meets the education and experience requirements outlined in the National Academy for Nuclear Training in its current guidelines for initial training and qualification of licensed operators. If you requested a deferral in item 12.a, you can still check Yes for item 20.a.

21. TRAINING - (For power reactors, if Yes is checked in items 20.a and 20.b, then this item is not required to be completed.) All re-qualification training time is to be accounted for in item 21.f (unless items 20.a and 20. b are are checked "Yes"). Do not double list the time spent in re-qualification training for classroom or simulator time under items 21.a or 21.b.

22. SIGNIFICANT CONTROL MANIPULATIONS - If you are a NEW applicant (item 11.a), you must provide evidence that you have successfully manipulated the controls of the facility for which a license is sought. Describe (date, time, type, and magnitude) at least five significant control manipulations that affect reactivity or power level and whether the manipulations were performed in the plant or on the simulator. If needed, use item 25, or attach a separate document to this form.

23. EXPERIENCE DETAILS - (For power reactors, if Yes is checked in items 20.a and 20.b, then this item is not required to be completed unless applicant is a certified instructor seeking an SRO license.) For each position held, provide position title, time in position (from/to and number of months), facility, and a description of duties performed while in that position. Do not double count time. If you had overlapping duties, the time should reflect the amount of time you were assigned to those particular duties. In no case should the number of months reported exceed the number of months that are in that time period. If more space is needed, use block 25, or attach a separate document to this form.

24. FOR RENEWALS ONLY - (a) Check the box that most accurately reflects your approximate number of operating hours since previous renewal or issuance of license if first renewal. (b) Enter the date and results of your most recent comprehensive written requalification examination and annual operating test.

25. 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 include extra information as a separate document with your application.

26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE, IS ATTACHED - NRC Form 396 and any applicable supporting medical documentation must accompany this application unless a waiver of the medical examination is being requested in item 12.c.3.

27. SIGNATURES - You must sign and date item 27.a. Obtain signatures of your training coordinator and the senior management representative on site.

NRC FORM 398 (MM-YYYY)

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)(continued)

How to submit this form: This form must be submitted by mail to the appropriate NRC office, at the address listed below, or by Electronic Information Exchange (EIE), or NRC Box (if a Box has been established to submit documents to the NRC). EIE is the preferred method. When using EIE: If a field is not applicable, leave the item block blank. If using a scanner to send the form, a scanner setting of 600 DPI is preferred. Do NOT include the form instructions when submitting completed NRC Forms 398 and 396. Detailed guidance on electronic submissions can be obtained by visiting the NRC's web site at http://www.nrc.gov/site-help/e-submittals; by e-mail to MSHD.Resource@nrc.gov; or by writing the Office of the Chief Information Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

ADDRESSES This form may be submitted by mail and addressed to:

REGIONAL ADMINISTRATOR, REGION I REGIONAL ADMINISTRATOR, REGION III U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION 2100 RENAISSANCE BOULEVARD, SUITE 100 2443 WARRENVILLE ROAD, SUITE 210 KING OF PRUSSIA, PA 19406-2713 LISLE, IL 60532-4352 REGIONAL ADMINISTRATOR, REGION II REGIONAL ADMINISTRATOR, REGION IV U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION 245 PEACHTREE CENTER AVENUE, NE., SUITE 1200 1600 E. LAMAR BOULEVARD ATLANTA, GA 30303-1257 ARLINGTON, TX 76011-4511 DIRECTOR, DIVISION OF ADVANCED REACTORS AND NON-POWER PRODUCTION AND UTILIZATION FACILITIES OFFICE OF NUCLEAR REACTOR REGULATION U.S. NUCLEAR REGULATORY COMMISSION WASHINGTON, DC 20555-0001 PRIVACY ACT STATEMENT NRC FORM 398, PERSONAL QUALIFICATION STATEMENT -- LICENSEE Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 398. This information is maintained as part of a system of records designated as NRC-16, described at 84 FR 71548 (December 27, 2019), or the most recent Federal Register publication of the NRC's "Republication of Systems of Records Notices" that is located in NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 42 U.S.C. 2131-2141; 10 CFR Part 55.

2. PRINCIPAL PURPOSE(S): To ensure that applicants/licensees meet all the requirements for taking reactor operator examinations.

3. ROUTINE USE(S): Information may be used to determine if the individual meets the requirements of 10 CFR part 55 to take an examination or to be issued an operators license; to provide researchers with information for reports and statistical evaluations related to selection, training, and examination of facility operators; to provide examination, testing material, and results to facility management. Information may be disclosed to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and foreign agency to the extent relevant and necessary for an NRC decision about you; in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosing this information is voluntary. However, if the information requested is not provided, NRC will not be able to evaluate whether the applicant meets the requirements of 10 CFR Part 55.

5. SYSTEM MANAGER(S) AND ADDRESS: Chief, Operator Licensing and Training Branch, Division of Inspection and Regional Support, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.