ML25342A385
| ML25342A385 | |
| Person / Time | |
|---|---|
| Issue date: | 12/08/2025 |
| From: | NRC/NRR/DRO |
| To: | NRC/OCIO |
| References | |
| OMB-3150-0024, NRC-2025-0011 | |
| Download: ML25342A385 (0) | |
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MAP-X MYPAGE SUPPORT ACCOUNT SIGNOUT MyPage MyPage - OperatorU Fonn396 PERSONALLY IDENTIFIABLE INFORMATION -WITHHOLD UNDER 10 CFR 2.390 Form 396 - CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE.
FiflH*ii,M Estimated burdefl per response 10 comply wtth this voluntary collection request: 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. NRC requires this informatioo 10 determine that the physical condttion and heaMh of operator licensees is such that the applicant woulcl not be expected to cause operational errors endangering the public health and safety Send comments regarding burden estimate to the FOIA, library. and lnformalioo Col~ions Branch (T-QA10M). U.S. Nuclear Regulatory Commission, Washington. DC 20555--0001, and the 0MB reviewef at: 0MB Office of lnfomlation aflCI Regulatory Affaifs, {3150-0024). Attn: Desk Officer lor trte Nuclear Regulatory Commission. 725 17th Street NW. Washington, DC 20503. Tile NRC may not conauct or sponsor, and a person is not require<! to respond to, a collection of Information unless the document requesting or requiring tile col~ion displays a currently valid 0MB cofltrol number.
APPLICANT INFORMATION WOMYYY "ApplicantAddress: Streetline1
- Applicant Address : City Applicant/Operator Docket Number
- Facility Docket Numbers Name 1--
Docket selection is required
- ApplicantAddress : State Select A. MEDICAL EXAM INFORMATION
- App licant Address: ZIP
- Applicant/Operator Ema il Addres s Docket Number
- 0.
l}[*l+H@Lf Region BASED ON THE RESU L TS OF THE PHYSICAL EXAMINATION, INCLUDING INFORMATION FURNISHED BY THEAPPLICANT/OPERATOR, 1 CERTIFY THAT THE ABOVE NAMED APPLICANT/OPERATOR HAS BEEN FOUND TO MEET THE MEDICAL REQUIREMENTS FOR L ICENSED OPERATORS AT TH I S FACILITY. I ALSO CERTIFY THAT IN REACHING THI S DETERMINATION, THE GUIDANCE CONTAINED IN THE ANSI STANDARD OR AN APPROVED NRC ALTERNATIVE METHOD WAS FOLLOWED AND THAT DOCUMENTATION I S AVAILABLE FOR REVIEW BY THE NRC.
- Guidance Used Select or search options Other Guidance
Enter PHYSICIAN'S DEGREE, PHYSICIAN' S PRINTED NAME, PHYSICIAN' S CERTIFICATION DATE, LICENSE NUMBER, ANO STATE OF LICENSURE.
Physicians Certification Date"' Date of physician's final certification of applicanVoperator's medical suitability (induding recommended license conditions) and/or the date of the physician's certification of a required medical status update (Check Box 7).
"Degree 5elect "Name of Physician
' Physician"s Certification Date (See instructions)
M/OMYYY
' License Number ii
' State 5elect BASED ON THE RECOMMENDATION OF THE PHYSICIAN, IT IS REQUESTED THAT THE APPLICANT/OPERATOR LICENSE BE CONDITIONED AS FOLLOWS (check allthatappty).
l icense Conditions - Check all the applicable boxes to request license condition(s). For each checked box in Nos. 4 through 11. provide supporting medical evidence that the requested license coodition addresses the disqualifying medical condition. The supporting medical evidence shall consist of a brief narrative from the examining physician (provided either in the "Explanation* box or in an attached letter) addressing the pertinent medical history. objective findings (for example, blood pressure.
HgA1C, and TSH), the diagnosis. and the recommended treatment (including name, dosing, and any adverse reactions), lo demonstrate the efficacy of the proposed license condition.
0 1. NO RESTRICTIONS.
Physical and mental condition and general health meet the minimum requirements, without exception 0 2. CORRECTIVE LENSES SHALL BE WORN WHEN PERFORMING LICENSED DUTIES.
corrective lenses must be worn to meet the minimum requirements for vision 0 3. HEARING AID SHALL BE WORN WHEN PERFORMING LICENSED DUTIES. THIS DOES NOT APPLY TO CONDITIONS THAT REQUIRE PROTECTION IN HIGH NOISE AREAS.
Hearing aid must be worn to meet the minimum requirements 0 4. SHALL TAKE MEDICATION AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS.
Meets the minimum medical requirements only by taking prescribed medication(s).
0 5. SHALL USE THERAPEUTIC DEVICE(S) AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS.
Meets the minimum medical requirements only by using a therapeutic device (e.g., CPAP and Spinal Cord Stimulator).
0 6. SOLO OPERATION IS NOT AUTHORIZED Another Individual, capable of summoning help must be present when the operator Is performing lieensed duties. Check the applicant/operator's license type 0 7. SHALL SUBMIT MEDICAL STATUS REPORT EVERY:
Medical conditiOn that requires more frequent monitoring than the two (2) years required by 10 CFR 55.21. It Other is checked, inelude the requested time rrame.
0 8. SHALL NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR.
Respiratory or integumentary (skin) condition 0 9. OTHER RESTRICTIONS OR EXCEPTION Other license conclition(s) necessary to mitigate identified medical or psychological issue(s) that do not meet minimum medieal requirements. use "Proposed Wor<l'ing or Restriction" and "Relationship of Restriction to Disqualifying Con<lition" boxes. If an applicant or operator fails to meet a medical requirement t>ut can demonstrate complete capacity to perform assigned duties, as proven by a test adminiStered by the physieian, the physieian may recommend and justify a waiver or that portion or the applicable ANSI standard. For an applicant the waiver request must be made on the NRC Form 398, "Personal Oualifieation Statement - Licensee," by Checking Box 12.c.3 and justifying the waiver/exception request in Box 25.
0 10. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL Additional license condition request, modiflCatiOn or an existing conditiOn or deletion or an existing conditioo. Must include an explanation in the Explanation Box and provide Medical Evidence.
D 11. Information Only Check box if providing required established medical status updates that do not request new restrictions, removal of restrietiOns or change in status report frequency.
Use for reporting any other medical situalion you determine that needs to be reporte<I to the NRC. Do not report temporary medical conditions for operators on administrative hOld.
D 12. supporting Documentation (Attach documentation in support of medical restrictions for new applicants/operators.)
B. APPLICANT/OPERATOR'S SIGNATURE Signature -Applicant/Operator D I acknowledge the intorm:ilion in this certification 3nd att3chments as they :1.pply to my licensure by the NRC. I :1.uthorize my f:1.cility to provide this certification and attachments to the NRC to use in the exercise of its authority over my ticensure.
Date MIONYYY ii C. FACILITY CERTIFICATION "Name and Tltle of Senior Management Representative Signature Senior Management Representative 0 I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION IN TH IS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
Date I M/ONYYY h*mm A ii Attach additional files:
I Choose FHe I No me chOsen Progress: 0.00 o/o SubmlssiOns Will not be made publicly available and will only be used by NRC staff.
Attached files:
File Size 0/900000 KB used.
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