ND-21-0427, Enclosure 3: Sample NRC Form 398 Personal Qualification Statement - Licensee

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Enclosure 3: Sample NRC Form 398 Personal Qualification Statement - Licensee
ML21189A157
Person / Time
Site: Vogtle  Southern Nuclear icon.png
Issue date: 07/08/2021
From:
Southern Nuclear Operating Co
To:
Office of Nuclear Reactor Regulation
Shared Package
ML21189A153 List:
References
ND-21-0427
Download: ML21189A157 (7)
v • d • e


Text

Southern Nuclear Operating Company ND-21-0427 Enclosure 3 Sample NRG Form 398 Personal Qualification Statement- Licensee (This Enclosure consists of 6 pages, not Including this cover page)

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390 NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY 0MB; NO. 31SO-OOSO eXPlftCS: 07/31f2022 DATE RECEIVED (10-2019) Esunatsd borden Esanatsa Cmrden per fBspoftte respome to cofTfJy conYily vitdt iha nmandatcry cdlsc^ requeat: 2.56 i>>u>>. NRC wfjt ttw (To b<< comptotod by NRC) 10 CFR 55.31,65.33, /.^ JS r ER30N AL. re<Mres !hbintefmaliofi f<<Mrei !hb inlymation toeit>>yr<<

to ensurt thai*petort&fcBna that apcUcarrt&fcBiTMu mee) <<l lt<< niQuir>>R<<rti br taVng reactor 55.35, 55.47, 65.63. 5 J atarNAaHora. S<<nj atarNAaiiortt. S<<rvj atmrwnu Ktrntftt regarding Isun) liun)en e&imaic la tfte Narmaitan S<<>vtee& Brancft and 55.57. ' tSMT#* DUAI (T4 Am fr4 A10U). u.s^

U.$. NuiSew Nudear Resiibrtofy RegUalcy Cwwiijjkyt.

ComBsbA. V/>>hbgton. CC 20555^1, or by e-rrui u VdCW/^l-ir i<<M^^ I IV/I^ lriSxo>>9ci>>,RasoufC.0TTCgo¥. atrf to fe Dett Offa^

kdbceBeda.Rasourca^mtgov. ard to Ihe Desk Offiosr.Ottca of Inforrraton and Regufatory Aftan.

OTP A TCHilCriLnr l NEO&-10202, 0150-^OW),

NEO&-1W02. 0150-^0^), Oftce Oftce of of Managemert Managamert Bf* ard Budget. Wathitg^ DC ^)503. V s tneartt OTATCmcNT ** LiCcNoCC I^ad to iiipc<<e ^icrmsuvt oActic^

used to in^xtse >>-t inbrmsUoA coiection do<< not (fispLiy a cuneoih vtAd CMS corrlidf fwrriber Tie NRC may rtot coodoa or tponxot, and a person Is not requii<<l to mpnnd is. tf<< infetmaiioA giacdcn,

2. First Nams 3. MIddIa InillBl Suffix 4. Birth Data; (MM/DO/YYYY) 5. E-mail Address (See box 27a. Eiactfonic correspcndence option)

Address (Number & Streel, line 1} 7. Address (Suite, Unit No, etc., line 2) 8. City ll.'iiType of Application (Check appllcabis boxes), 12.: GFE and DofoiTals/fxcusala/Walvars (Se© inslructJons, check alMhai apply and justrfyjn Ifin 2C)

I I A. NEW [))] E, REAPPLICATIDN I I a. DEFERRAL IS g b. EXCUSAL c. WAIVER

[ I B. RENEWAL ME 1 .FIRST DENIAL I I 1-ELIGIBILITY 1-WRITTEN (Category) SSR 1-WRITTEN (Category) GFE r~l C. UPGRADE HI 2.SECOND DENIAL II\m\rnd. DATE 2-EXPERIENCE [g 2 - OPERATING (Category) OPT [)) 2-OPERATING (Category)

>1 PASSED GFE Q 3-MEDICAL O. MULTl-UNfT (amend m to indude additional unit) 3.THIRD DENIAL

4. WITHDRAWAL (MM) September (09) EJ (YY) 18 Q 4.OTHER IH
13. Type of License Applied for: g OPERATOR (RO) [))] SENIOR OPERATOR (SRO) n LIMITED (LSRO)
14. Pocket and Licensing Information Docket Number Expiration Dale(s} Facility Oockst Number (Separate muttiple docket numbers by V)

[] "o ticensa Number(8) xxxxx LSRO OPXXXXXX 7/28/2026 050 025 Q SRO H 052

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

VEGP 3 & 4 050 025 026

[l 052 18/Current Position at Facility :

I I A. Plant SupervisorfManager I I E. Shift Technical Advisor/Shift Engineer 11 I I. Trainee 8- Assistant Plant Supeiintendent/Manager I I F. Instructor I I J. Non-Ucenaed Operator I I C. Shift Supervisor I I G. Senior Control Room Opei^tor I (Z]

I I D. Staff Engineer Bj H. Control Room Operator

' 19. Educ-it.0'1

a. High School b. College DEORES CCOES c. Vocatlooal/Technlcal Cortiflcslo Rscfiivad

, obiaifwd) Type of Training Number HIGHEST DECREE 0-Nooa

[b] Graduate Major Ar6a(s) of Study ofYsnfS (UwCodo) t - CeriLlcais

[_] GEDEqulval ancy l Engineering 2-A5>>oc>a?<<

3 - asch^or No lOih<<c I

I I

4

  • Mn>>1#r 5.0oct<<<l S
  • Oocforat I [ [ Yes No 20.\Power ReactorOi^ratorTraining Prograrn * ' x
a. Has the applicant completed the Operator Training Program accredited by the Nationai Nuclear Accrediting Board?

13 D

b. Is a "Plant-Referenced Simulator" (As defined In 10 CFR S5.4) used In the Operator Training Program? (§ Y., No 21, Training (Since Last Application-See Instructions)
a. Classroom From (MM/YYYY) From (MM/YYYY) To (MM/YYYY) No. ofWooks 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 DESCR PT ON DESCR PTION PLANT SIMULATOR NRC FORM 398 (10-2019) Page 1 of 3 Page 1 of 6

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (10-2019)

ID CFR 55.31,55.33, 55.35, 55.47. 55.53, and 55.57.

PERSONAL QUALFICATION STATEMENT - LICENSEE (Continued) 1, Last Name 2. First Name 3. Middle rniUal Suffix Docket Number 055-

23. Nuciesr Exportenca Details FROM DATE TO DATE POSITION TITLE MONTHS FACILrrY DUTIES (MM/YYYY) (MM/YYYY)

Nuclear Plant Operator Vogtle Electric Generating Plant 3 &

4

24. For Renewals Only MM/YYYY Resultt rn <100(LESS THAN) b. Date and result of last
a. Hours Operated Facility written comprehensive Q] 100 -1000 requalification exam and W (H "PAS n pA'i-

>1000(MORE THAN) annual operating test.

o PASS fail

25. Commenis BLOCK 12 Item b.1 and b.2: An excusal is requested due to applicant successfully passing all portions of a prior NRC examination (see exemption approval dated XX-XX-XX)

BLOCK 12 Item c.1 and d - GFES WAIVER: A waiver is requested from the requirement of NUREG 1021, ES-202.C.1.b, to complete the GFE 'within 24 months before the date of application.' Pursuant to ES-204.D.1 .k(4), the regional office may waive this requirement if the applicant has been a full participant in the licensed operator requalification program, including satisfactory performance on the operator or senior operator annual and biennial requalification examinations. This applicant meets the criteria for a waiver of ES-204.D.1.k{4) because they have been continuously enrolled and met all requirements of requalification.

26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED Q Yes No NRC FORM 398(10-2019) Page 2 of 3 Page 2 of 6

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION

{10-2019) 10CFR 55.31,55.33.

55.35, 55.47, 55.53.

and 55.57.

PERSONAL QUALIFICATION STATEMENT - LICENSEE (Continued)

1. Last Name 2. FiratName 3. Middle Initial l Suffix Docket Number 055
27. Signdturos ANY FALSE STATEMENT OR OMfSSfON iN THIS DOCUMENT,INCLUDING ATTACHMENTS, MAYBE 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 the NRC to submit the results of examinations to my employers for use In preparing retraining programs, as necessary.

Signature

  • Applicant (Sign In Black Ink) Date I I Electronic Correspondence Option: By checking this box. you are acknowledging that the NRC will be providing operator licensing correspondence electronically.

27b. CHECK APPLICABLE BOX(ES)FOR TYPE OF APPLICATION (I.e., check 11f 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 thai:(1)the above named Individual has successfully completed the facility licensee's requirements to be licensed as an Operator/Senior Operator pursuant to TitieiO, Code of Federal Regulations, Part 55;(2)the individual has a need for an Operalor/Seniof Operator license to perfomi 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 excepUons noted in Item 25)required by section 50.54(1-1) of 10 I I 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 tme and correct.

gj 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 IndMdual. I also certify under penalty of pegury that the Information in this document and attachments is true and correct in accordance with the instructions.

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

Henry Curry, Training Director Signature (Training Coordinator)(Sign In Black Ink) Date Senior Managomont R:eprasentative on Site Typed or Printed Name and Title (Senior Management Representative on Site)

Glen Chick, Executive Vice President Signature (Senior Management Representative on Site)(Sign In Black Ink) Date FOR NRC USE GRANTED BY DENIED BY Deforral/Excusal/Waiver Requests (Check or Complete items, as applicable) HEADQUARTERS REGION HEADQUARTERS REGION Eligibility Deferral Experience Written Excusai Operating Written Operating Waiver Medical Other Explanation:

Q MEETS REQUIREMENTS Q DOES NOT MEET REQUIREMENTS Signature (Sign In Black Ink) Date NRC FORM 398(10-2019) Pago 3 of 3 Page 3 of6

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390 NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY 0MB; NO. aiSO-OOSO EXPIRES: 07/3112022 DATE RECEIVED (10-2019) EswiatwJ burden per f<<pon>> to conjpfy nvith Cw tnaodawry coSecton regont 2.56 hoof*. KRC (TQbo cwnpAr/ed by NRC) 10 CFR 55.31,55.33. A A PERSONAL this infomuSon Id ensDrgt that SDf/cantsitatnseaf meiK ail iha rMfubrtmeitU for tiMag reactor 55.35, 55.47. 55.53, 5 , operator eiarnina(ons. Send convnents reganltog butoen Mtmato to the toCannatioR Servtes Brandt and 55.57. (T^ A1CM), U.S. Mucfcar Regulatory Conw>>l<<fon. Wwhiftgtoo. DC 20655^1. or by to QUAUFICATION infoca!adsitesourta^)rn;.Q<>v. and to the Oesl: OflkBr.OfRoa ol ^formation and RegUatory AflaH.

NEOB-1Q202,(31S04K)90}. Ofios of Managemanl and Budget. Watfrnglon. DC 20501 tf a meara STATEMENT - LICENSEE mad to imposs an information coOeclion does not dbpby o cunerdy vaGd 0M8 oonbol nuntoer. the NRCmaynotoondwctorcponsor.endapertonisrtotregiirediotesp^ to.thoinforinstonajltociion.

1. Last Name 2. First Name 3, Middle Initial 4. Birth Date: (MM/OO/YYYY) 5. E-mail Address(Sea box 27a. ElecUonic cotrespondence option) 6, Address(Number & Slroat. line 1) 7. Address (Suite. Unit No,etc.. line 2) 8, City 9. State 10. zip Code
11. Type of Application (Check applicable boxes)

GA

12. 6F£ and Deferrals/Excusals/Walvers(See Instrudjons. check all that apply and justify In item 25)

B I A. NEW I I E- REAPPLICATION a, DEFERRAL c, WAIVER B. RENEWAL I I 1 - FIRST DENIAL 1 . EUGIBILITY 1 - WRITTEN (Category) SSR 1 -WRtTTEN (Category) GFE C. UPGRADE I I 2-SECOND DENIAL 2 - EXPERIENCE 2 - OPERATING (Category) OPT 2 - OPERATING {Category)

D, MULTI-UNIT (amend to Include additional unit) 3 - THIRD DENIAL d. DATE PASSED OFE I I 4-WITHDRAWAL I I 4-OTHER 13, Type of License Applied for; [)) OPERATOR (RO) \m\ SENIOR OPERATOR (SRO) Q LIMITED (LSRO)

14. Docket and Licensing Information Dochet Number License Number(8) Expiration Date($) Feclllty Docket Number (Separate multiple docket numbers by *;*)

[Ml 055. XXXXX n lsro SOPXXXXXX 7/28/2026 050 025 n SRC [1] 052

15. Nams of AppilcanCs Facility 16. Facility Docket Number 17, Additional Facility Docket Number(s) (Multi-unit Licenses)

VEGP 3 & 4 050 025 026

[i] 052

18. Current Position at Facility I I A. Plant Supervlsor/Marwiger Q E. Shift Technical Advisor/Shift Engineer I I I. Trainee I I B. Assistant Plant Superintendent/Manager ( I F, Instructor rn J. Non-Licensed Operator I I C. Shift Supervisor G. Senior Control Room Operator Q K. Other j I D. Staff Engineer I H. Control Room Operator
19. Education
a. High School b. College DEGREE COOES c, Vocational/Technical Numbor of fHighaet Oogree* obtained) Months Certificate Received Type of Training

[pl Graduate Major Afea(s) of Study Mumttor of Veftra HIGHEST DEGREE (Una Code$}

O-None

\

  • Certiacata 1 1 QED Equivalency Engineering
2. A#<<>cia!a 3-Bachelor No
4. Master No Otfwr 5-Doctoral NO
20. Power Reactor Operator Training Program
a. Has the applicant completed the Operator Training Program accredited by the National Nuclear Accrediting Board? fi] Yes
b. Is a "Plant-Referenced Simulator" (As defined In 10 CFR 55.4) used In the Operator Training Program?
21. Training (Since Last Application << See Instructions)
a. Classroom From (MMhrVVY) To (MM/YYYY) Mo. of Waok# From (MM/YYYY) To (MM/YYYY) No. efWoQXd 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. Requailfication
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. 1 1 i.
e. J.

NRC FORM 398(10-2019) Page 1 of 3 Page 4 of 6

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee NRG FORM 398 U.S. NUCLEAR REGULATORY COMMISSION (10-2019) 10 CFR 55.31. 55.33, 55.35, 55.47. 55.53.

and 55.57, PERSONAL QUAUFICATSON STATEMENT - LICENSEE (Continued)

1. Last Name 2. First Name 3. Middle Initial Sufflx Docket Number 055.
23. Nuclear Experlonco Details FROM DATE TO DATE POSITION TITLE MONTHS FACILITY DUTIES (MMATYY) (MM/YVYY)

Senior Reactor Operator VEGP 3 & 4

24. For Renewals Only

< 100 (LESS THAN) b. Data and result of last MM/YYYY Result

a. Hours Oporated Facility Q 100 -1000 written comprehensive W Q PASS fail requalification exam and

((] >1000 (MORE THAN) annual operating test. 0 PASS fail

25. Comments BLOCK 12 Item b.1 and b.2: An excusal is requested due to applicant successfully passing all porttons of a prior NRC examination (see exemption approval dated XX-XX-XX)

BLOCK 12 Item c.1 and d - GFES WAIVER: A waiver is requested from the requirement of NUREG 1021, ES-202.C.1 .b, to complete the ORE 'within 24 months before the date of application.' Pursuant to ES-204.D.1,k(4), the regional office may waive this requirement if the applicant has been a full participant in the licensed operator requalification program, including satisfactory performance on the operator or senior operator annual and biennial requalification examinations. This applicant meets the criteria for a waiver of £S-204.D.1.k(4) because they have been continuously enrolled and met all requirements of requalification.

26. NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED Ves No NRC FORM 398(10-2019) Fage 2 of 3 Page 5 of 6

ND-21-0437 Sample NRC Form 398 Personal Qualification Statement - Licensee NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION

{10-2019) 10CFR 55.31.55.33, 55.35, 55.47. 55.53, and 55.57.

PERSONAL QUALIFICATION STATEMENT - LICENSEE (Continued)

1. LastNamo 2. First Name 3. Middle initial I Suffix Docket Number 055 -

27^ Signatures ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT INCLUDING ATTACHMENTS, MAYBE 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 the NRC to submit the results of examinations to my employers for use In preparing retraining programs^ as necessary.

Signature<<Applicant(Sign In Black Ink) Date I I Electronic Correspondence Option: By checking this box, you are acknowledging that the NRC will be providing operator licensing correspondence electronically.

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 chocked.) l

1. I certify lhat:(1)Ihe above named individual has successfully completed the facility licensee's requirements to be licensed as an Operator/Senior Operator pursuant to TillelO, 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 penally of perjury lhat the information In Itils document and attachments Is true and correct in accordance with the instructions.
2. I certify lhat the above named individual completed the approved requalifjcation program (with the exceptions noted in Item 25)required by section 50.54(i-1) of 10 CFR 50,and lhat 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)

Henry Curry, Training Director Signature (Training Coordinator) (Sign In Black Ink) Date Senior Management Representative on Site Typed or Printed Name and Title (Senior Management Representative on Site)

Glen Chick, Executive Vice President signature (Senior Management Representative on Site) (Sign In Black Ink) Date FOR NRC USE GRANTED BY DENIED BY Oeferral/Excusal/Walver Requests (Check or Complete items, as applicable) HEADQUARTERS REGION HEADQUARTERS REGION Eligfbimy Deferral Experience Written Excusal Operating Written Operating Waiver Medical Other Explanation; r~l MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS Signature (Sign In Black Ink) Date NRC FORM 398 (10-2019) Page 3 of 3 Page 6 of 6

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