NRC Form 396
Licensed Medical examination form.
Required 6 months prior to the issuance of a license. Usually accompanying NRC Form 398.
Required to be resubmitted every 2 years per 10 CFR 55.21.
When making an update, included all other restrictions. The form should be a reflection of the current state.
File:NRC Form 396-jb.pdf - This version of the file can be saved
FAQ Page
The NRC have a series of questions and answers pertaining to NRC Form 396 and submitting medical information.
Instructions
Enter NAME OF APPLICANT, as it appears on NRC Form 398 (NoteNote: (Last, First, Middle)), and the applicant's DOCKET NUMBER Enter name of FACILlTY(IES) and FACILITY DOCKET NUMBER(S) for which a license is sought as it (they) appear(s) on NRC Form 398.
Enter the PRINTED NAME (of physician) and other medical professionals (e.g., nurse practitioners and physician's assistants) who performed the physical examination. The examining physician may delegate portions of the examination to a licensed nurse practitioner or a licensed physician's assistant who is familiar with the applicable ANSI standard and the activities required of a nuclear power plant operator or senior operator. However, the physician has the ultimate responsibility for certifying that the medical examination was conducted in accordance with the ANSI standard and that the applicant meets the medical requirements. The STATE AND LICENSE NUMBER(S) of all the medical practitioners significantly involved with the examination (Le., not laboratory technicians) should be entered on NRC Form 396.
Enter the DATE of the applicant's MOST RECENT BIENNIAL MEDICAL EXAMINATION. For new license applicants (Le., ROs and instant SROs), the medical data in support of NRC Form 396 are normally good for six months from the date of the medical examination. If more than 6 months have passed since the date of the medical examination, the facility licensee shall certify in writing that the applicant has not developed any physical or mental condition that would be reportable under 10 CFR 55.25; this should be done in Item 17, "Comments," of the associated license application (NRC Form 398). If the applicant's medical condition has changed or the time since the applicant's last medical examination is expected to exceed 24 months before the licensing action is completed, the applicant must be reexamined by a physician.
Check (or specify) which GUIDANCE document was USED to determine that the applicant's physical condition and general health are such that the applicant would not be expected to cause operational errors endangering public health and safety. Use the numbered blocks to identify any and all license restrictions, changes, or waivers (exceptions) that might be necessary.
Check 1. NO RESTRICTIONS
if, in the physician's judgment, the applicant's medical condition and general health will not adversely affect the performance of assigned operator job duties or cause operational errors endangering public health and safety (Le., the applicant satisfies, without exception, all the criteria specified in the applicable ANSI standard).
If accompanied with the normal NRC Form 398, License Application or Reneweal, than a healthy operator gets this checkbox. Or, if a restriction is dropped and there are no others.
Check 2. CORRECTIVE LENSES SHALL BE WORN WHEN PERFORMING LICENSED DUTIES
if the applicant must wear corrective lenses in order to achieve the near and distant visual acuity specified in the applicable ANSI standard.
Check 3. HEARING AID SHALL BE WORN WHEN PERFORMING LICENSED DUTIES
if the applicant must wear a hearing aid in order to achieve the audiometric scores specified in the applicable ANSI standard.
Check 4. SHALL TAKE MEDICATION AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS
if the applicant's medical qualification per the applicable ANSI standard is contingent on taking a prescription medication.
Check 5. SHALL USE THERAPEUTIC DEVICES(S) AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS
if the applicant's medical qualification per the applicable ANSI standard is contingent on using a therapeutic device (e.g., CPAP).
Check 6. SOLO OPERATION IS NOT AUTHORIZED
if another individual must be present (as specified in Section C.3.c of ES-605 of NUREG-1021) when the applicant performs licensed duties.
Check 7. SHALL SUBMIT MEDICAL STATUS REPORT EVERY 3, 6, or 12 MONTHS
if the applicant's medical condition requires more frequent monitoring (than every 2-years) to ensure compliance with the applicable ANSI standard.
Check 8. SHALL NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR
if the applicant suffers from a respiratory condition that would preclude the wearing of a respirator.
Check 9. OTHER RESTRICTION OR EXCEPTION
if, in the physician's judgment, any other license condition is necessary to accommodate any identified medical or psychological situation that does not meet the minimum requirements in the applicable ANSI standard. Fill out the PROPOSED WORDING OF OTHER RESTRICTION block, briefly explain how the recommended restriction will correct or accommodate the disqualifying condition in the RELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION block, and attach the supporting medical evidence for review by the NRC. If an applicant fails to meet a medical requirement but can demonstrate complete capacity to perform assigned duties, as proven by a practical test administered by the physician, the physician may recommend, and similarly justify, a waiver (exception) of that portion of the applicable ANSI standard. In all cases, check Item 4.f.4 on the associated license application (NRC Form 398).
Check 10. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL
if the physician recommends the modification or deletion of an existing restriction. Include an EXPLANATION FOR RESTRICTION CHANGE in the space provided.
This should be interpreted that if any restriction status is changed, new, or deleted. Basically when one of the toggle restrictions (y/n) are modified.
Check 11. INFORMATION ONLY
if the form is being used simply to forward updated medical information (e.g., a 6-month blood pressure report required by an operator's license condition) to the NRC for evaluation. Be sure to attach supporting information, if necessary.
Signature
The Officer of the company is the Site VP person filling in for SVP for the day. This instruction is ambiguous and it may mean that a different person such as the Ops manager could sign this form.
See also
CFR
- 10 CFR 55.21, Medical Examination
- 10 CFR 55.23, Certification
- 10 CFR 55.25, Incapacitation Because of Disability or Illness - 30 day notification requirement for disability
- 10 CFR 55.33, Disposition Of An Initial Application
- 10 CFR 50.74, Notification Of Change In Operator Or Senior Operator Status - 30 notification as well for other things
Information Notices
- Information Notice 1991-08, Medical Examinations for Licensed Operators
- Information Notice 1994-14, Failure to Implement Requirements for Biennial Medical Examinations and Notification to the NRC of Changes in Licensed Operator Medical Conditions
- Information Notice 2004-20, Recent Issues Associated with NRC Medical Requirements for Licensed Operators
- Information Notice 2009-21, Incomplete Medical Testing for Licensed Operators
- Information Notice 2012-10, Recent Issues Associated with Submittal of NRC Form 396, Certification of medical Examination by Facility Licensee, for Applicants and Licensed Operators at Non-Power Reactors