ML25014A340
| ML25014A340 | |
| Person / Time | |
|---|---|
| Issue date: | 11/14/2025 |
| From: | NRC/NRR/DRO |
| To: | NRC/OCIO |
| Shared Package | |
| ML25010A370 | List: |
| References | |
| OMB-3150-0090, NRC-2025-0012 | |
| Download: ML25014A340 (6) | |
Text
MyPage MyPage-OperatorU Form398 PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390 Form 398 - Personal Qualification Statement - Licensee Estinatell tluRlell per response to oomplywill'llhismaooatoryOOled.::tl reqoest. 5.3 OOUS. NRC requi'esttusinkl!rnabOl'ltoensure lhalapplicallW<<el'lsees mettal llle 1eQwernentslortakilgreactoroperatorexanwiauons. sendcormiernreganlilgbl.rtlelles1JmatetotlleFOtA. t ibrary,andlnformabOl'ICOledionsBr¥dl(T-6A10M). U.S.
tluelealRegl.Catoryc<<nmissiM.washirlJ!on, OC:20555-00:11 orbyemai 10 1nklcoleds.Rescure@ruc.QO'l. aridllleOMBre-.iewefal.OMBOfluol lnkl!rnalior1ancl RegulatoryAl!an. (3150-0090).Attn,DeskOfflcerlorllleNudearRtgulatoryCOrmlissror\\12517lhStreettNi. Waslwlg1on,DC20503. TheNRCmayOOloondudorsponsor.
aooapersonis0011eQUl"elltoresp:inato. aCOlectionolinlormalior1un1eSStneOOCU'OenlrequeslnJor1eQuinngtneeollectO'l~aarrenttjl'illilOMBoontrotl"klrltlef FORM INFORMATION How to compleledlis form:Youmustcompltttitems1 -4and&-10and.J<ldibonalitemsasspecitiedbllowin1!1tinslructionslor Block\\1, "l'fpeorApplic.ltion." f or additionalguidaflet rtftr IC NUREG-1021, "Operator t ic:tnsl119 Eumin.ruor, SUndaids tor Powtr Rt~tors," or NUREG-1478, "Ho/1.P°"""r Reactor Operator Lletnslng Enmlntr SUIIC"ards.*
- 5. E mail Address
- If you provide an email address. you are electing to receive operator licensing correspondence from the NRC. electronicalty. If you do not provide an email address, the NRC will correspond using mail to the address you provided in Items 6-10
- 6. A ddress (N u m b e r & Street. line 1)
- 7. A d d ress { Suite, U nit No, etc, line 2)
- s. crty
- 10. Z ip Code 11. Type of A p plication ( Select all applicabl e)
A. N EW - SeleCt if you are a new applicant at tnis facility (I.e.. tnis is your first request to take tne site-specif.c NRC exam at tnis facility). Complete items 11 -13, 14 (tf applicaDle), and 15-23. If 20.a and 20.0 are cnecked "YesH tnen item 21 does not nave to oe comp1etea.
B. R ENEWA L - Select if you are renewing a c urrent license. Complete items 11, 13. 14, 18, 20. 21.f and 24; if items 20.a and 20.D are cneckea ~es*, tnen item 21 does not nave to oe compIetea.
C. UPGRADE - Select tfyou nold an RO license and are apptying to upgrade your license to an SRO at tne same facility. Complete items 11-18, 21 and 23 relevant to tne SRO upgrade. If items 20.a and 20.D are cnecked "Yes". tnen item 21 does not nave to De completed.
o. M ULTI-UNIT - Select if you nold a license at your facility and are applying to amend your current license to an additional unit. Complete items 11 -19, and 2 1-23.
Complete item 21 as it applies to unit differences.
E. R EAP PLICATIO N - Select tfyou nave previously Deen denied a license. Complete items 11 -19. 21-23, 25. Indicate whetneryou are applying after a first denial, second denial, or tnird denial. Descrit>e, in detail, in items 2 1 and 25, tne additional training completed since the last denial. If you previously witndrew an application, select -WitndrawaI* under " Reapplication Type."
~Ty p e{ s ) of Application Select or search options
- 12. Oeferrals/Excusals/Waivers (Select all applicable)
- a. DEFERRAL - Select if you are requesting a deferral or certain requirements lo be able lo sit for the scheduled NRC exam. Check which requirements (Eligibility or Experience) you are requesting deferral of. Identify the specific requirement and indicate the expected completion time for each requirement in item 25.
- b. EXCU SAL - Select if you are requesting to have a previously passed portion or the NRC exam excused. Indicate Which requirements of the requested portion you are requesting excusal from (Written or Operating) and indicate the category.
For Power Reactors: For written examination excusals, select excusal from the drop down box, then select Excusal Type or written. Under the wrmen category drop down select a category or "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. Select Excusal from the drop down box, then select Excusal Type or Operating. From the Operating Category drop down select 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, "0TH" 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, select excusal from the drop down box, then select Excusal Type of Wrttten from the drop down box. Under the Written Category drop down select "Excusal of category of A" to request an excusal of category A, select "Excusal of category of B" to request an excusa1 or category B, select ~Excusal of category of c~ to request an excusal or category C. For operating test excusals, select Excusal from the drop down box, then select Excusa1 Type or Operating. From the Operating Category drop down select a category of "ALL" to request excusat of an operating test. Individual categories of the operating test will not be excused. Provide justification in item 25.
- c. WAIVER - Select if you are requesting a waiver (55.47). For waivers of the wrttten examination and/or operating test, select Waiver from the drop down box, then select Waiver Type of Written or Operating respectively and identity 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.
Excusal / Deferral / Waiver Select or search options "13. Type of License Applied For Select Operator Docket Number
- 14. (Continued) License Information License Number There are no records to display.
- 14. (Continued) Current Facilities Facility Name t There are no records to display License Type select Expiration Date Docket Number l#li*HHI F-f.l*l*Mi#iiMl,iWE Region
- 15. Name of Applicant Facility 16 & 17. Facility Docket Number(s)
Facility Name t There are no records to display.
- 18. Current Position at Facility
- Current Position Select E*i-t*l*t-§@li&l:1-¥1 Docket Number Region
- 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 vocationavtechnical, enter the number of months for each type of training and Whether a certificate was awarded. If additional space is needed. use item 25
- a. High School Education Select
- b. College Highest Engineering Degree 0-None Highest other Degree 0-None
- c. Vocational/Technical Vocational Ttaining There are no records to display ml Months of Ttaining Certificate Received
- 20. Power Reactor Operator Tl'aining Program-(This item is not applieable to non-power reactors). Check the appropriate bOx in items 20.a and 20.b. Checking -Yes*
in item 20.a inclicates 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 tile National Academy for Nuclear Training in its current guidelines for initial training and qualification of licensed operatOfS. If you requested a deferral in item 12.a, you can still check 'Yes* for item 20.a.
- a. Has the applicant completed the Operator Ttaining Program accredited by the National Nuclear Accrediting Board?
@ No O ves
- b. Is a 'Plant-Referenced Simulator' (As defined in 10 CFR 55.4) used in the Operator Training Program?
@ No 0 Yes
- 21. Training (Since last application)- (For power reactors, if-Yes" is checked in items 20.a and 20.b, tllen 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. bare are checked "YesM). Do not "double lisr the time spent in re.qualification training for classroom or simulator lime under items 21.a or 21.b.
- a. Classroom 1-Nuclear Power Plant Fundamentals From To No. of Weeks I MIDNYYY ii I MIDfYYYY ii 2
- Plant Systems From To No. of Weeks I MIDNYYY ii I MIDNYYY ii 3-Plant Procedures From To No. of Weeks I MIDNYYY ii I M/D/YYYY ii
- b. Simulator From To No. of Weeks I MIDNYYY ii I M/D/YYYY ii
- c. SRO Instruction From To No. of Weeks I MIDNYYY ii I M/D/YYYY ii
- d. Extra Person on Shift in Control Room From To No. of Weeks I MIDNYYY ii I M/OfYYYY ii
- e. Time on Shift Above 20% Power From To No. of Weeks I MIDNYYY ii I MIDNYYY ii
- f. Requalification From To No. of Weeks I MIDNYYY ii I MIDfYYYY ii
- g. Other (Specify below)
From To No. of Weeks I MIDNYYY ii I M/0/YYYY ii Other Training Description t Plant or Simulator Ttiere are no records to display.
Position Title t From Date To Date Months Facility There are no records to display.
- 24. For Renewals Only * (a) Select what most accurately reflects your approximate number of operating hours since previous renewal or issuance of license if first renewal. (b) Enter the date and resuns of your most recent comprehensive written requalification examination and annual operating test.
1-Mif:EMM:E IW&i:li:iii Duties
- 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 A FACILITY LICENSEE, IS ATTACHED
- NRC Form 396 anel any applicable supporting medical documentation must accompany this applicatiOn unless a waiver of the medical examination is being requested in box 12.
@ No O Yes
- 27. Signatures ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
27a. I (certify under penatty of pe~ury that the informatiOn in this document and attachments is true and correct in accordance with the instructions. I also authOrize the NRC to submit the resutts of examinations to my emplOyers for use in preparing retraining programs, as necessary).
You must sign anel date item 27.a. Obtain signatures of your training coordinator anel the senior management representative on site Applicant signature Applicant Signature Date 0 1. I certify that: (1) the above named individual has successfully completed the facility licensee's requirements to be licensed as an OperatorfSenior Operator pursuant to Trtle10, 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 D 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.tnd attachments is true.tnd correct O 3. r 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
- ,Yped or Printed Name and Trtle (Training Coordinator)
Training Coordinator Signature Training Coordinator Sign Date Senior Management Representative on Site
- ,Yped or Printed Name.tnd Trtle (Senior Management Representative on Site)
Senior Management Signature Senior Management Signature Date Associated 396 forms IM¥MW First Name Last Name NRC Plant Name (Facility)
Title t Created On There are no records to display.
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