NRC Generic Letter 1983-12

NRC Generic Letter 1983-012: Issuance of NRC Form 398 - Personal Qualifications Statement - Licensee

ML031080503
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, South Texas, San Onofre, Cook, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000514, 05000000, 05000496, 05000497, 05000515, Zimmer, Fort Saint Vrain, Washington Public Power Supply System, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Cherokee, Clinch River, Skagit, Marble Hill, Black Fox
Issue date:	02/24/1983
From:	Eisenhut D Office of Nuclear Reactor Regulation
To:
References
GL-83-012, NUDOCS 8302250505
Download: ML031080503 (4)

FEB 2 4 1983 TO ALL POWER AND NONPOWER REACTOR LICENSEES, APPLICANTS FOR AN OPERATING

LICENSE, HOLDERS OF CONSTRUCTION PERMITS AND NSSS VENDORS

(GENERIC LETTER - 83-12)

Gentlemen:

Subject: Issuance of NRC Form 398 - Personal Qualifications Statement - Licensee Enclosed is a copy of the new NRC Form 398 - Personal Qualifications Statement Licensee. This form must be submitted by all applicants for operator and senior operator licenses under 10 CFR 5Find applicants for instructor certificates. No other information or documents are required beyond that which is requested in the instructions and the form itself.

Please read all instructions carefully before completing this form. Note that the form is to be submitted in triplicate.

All applications for licenses (including new applications, renewals, upgrades, reapplications and amendments to licenses) are to be submitted on Form 398 beginning no later than one-month from the date of this letter. To insure that our records are complete and accurate, we request that the Initial submittal of Form 398 by an applicant be completed with respect to all infor- mation requested. Subsequent submittals of Form 398 require completion only of that information that has chanqed since the previous submittal of this form, per the instructions provided. Questions regarding proper completion and usage of Form 398 should be directed to your appropriate Regional or Headquarters Operator Licensing Branch staff.

Requests for Form 398 should be directed to Vivian Miller, Nuclear Regulatory Comnission, Document Management Branch, M.S. W-548, Washington, DC, 20555.

Allow two weeks for delivery. Copies of this form can be duplicated, if necessary.

This request for information was approved by the Office of Manageipent and Budget under clearance number 3150-0090, which expires on August 31, 1985.

Sincerely, Darrell G. Eisenhut, Director X 52 Q2 Division of Licensing Enclosures: XZ4 Qfac4k*j NRC Form 398 V

Personal Qualifications S tement -

LFFens.e .......

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OFFICE ................

Lcne W........ ... ...k .~.N. . .................

SURNAMED ........ i .. ......... .......... ........................

.............. ........ ..;......en

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DATE .. ./.. . .... 83 .. 2.. . .. ........................ ...........

............. ......................

URCFORM318 4 OFFI IAL RECORD COPY USGPO: 1981-335-960

,-,. J l

~INSTRUCTIONS FOR COMPLETION OF

-

NRC FORM 398, PERSONAL QUALIFICATIONS STATEMENT- LICENSEE

i the instructions below.

NEW APPLICANTS: Complete each category of the form completely, following Complete all Information that has changed since your previous RENEWAL, UPGRADED, MULTI-UNIT, AND REAPPLICATION APPLICANTS: information:

submittal of an NRC Form 398. In addition, be sure to complete the following I - YOUR FULL NAME 5-TYPE OF LICENSE APPLIED FOR

4-TYPE OF APPLICATION 6- PREVIOUS LICENSES AND/OR DOCKET NUMBER HELD

SPECIFIC INSTRUCTIONS FOR ITEMS 11 - 17:

school education. For MAJOR AREA(S) OF STUDY, Indicate

11 - EDUCATION: Indicate both academic and vocational/technical post high using the degree code provided. For VOCATIONALJTECH-

collere curriculum and the highest degree received, the number of years spent In each air conditioning/refrigeration, diesel mechanic school, etc. In- NICAL education, Include programs such as nuclear power school, military training, or degree was awarded. If additional space is needed, continue under ITEM 15.

dicate the number of months in each program and whether a certificate the requirements of ANSI N18.1/ANS 3.1. The breakdown of

12 - TRAINING: In this item indicate the training you have received to meet you need further clarification. Include both beginning and com- please refer to the standards If training in this category parallels the ANS standards: OF WEEKS is provided, in addition to beginning and comple- pletion dates and the total number of weeks spent in each type of training. NUMBER

tion dates, to account for Intermittent training Ifor example, four weeksspent of classroom training spread over a two month period). Therefore, the date span than the actual number of weeks in full-time training.

columns.may Indicate a larger time item. Please avoid "double listing" recording all time spent All requalification training time Is to be accounted for in the REQUALIFICATION include classroom or simulatortime.

under item 12.6, REQUALIFICATION, even though It may in requallficatlon training

13 - EXPERIENCE: For each position held, complete item 14.

of duties performed while serving In that position. If more

14 - EXPERIENCE DETAILS: Include position title, facility, and abrief description space Isneeded, use item 15, or if necessary attach additional information.

for other items on the application form. If the space provided

15 - COMMENTS: Use this space to include any extra information or clarification is not sufficient, you may attach extra Information with your application.

a completed NRC Form 396 with each application In order

16 - NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION: Include forward the form as soon as possible: make sure all items are

16b, and to limit delays in issuing licenses. If this Is not possible, place an "X' in Item completed.

signature and that of your highest level of corporate man-

17 - SIGNATURES: Sign and date item 17a. Obtain your Training Coordinator's agement for plant operations.

398, IN TRIPLICATE AND 396 TO:

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS

Branch Chief, Operator Licensing Branch or the appropriate Regional Administrator.

PRIVACY ACT STATEMENT

of 1974 (Public Law 93-579), the following is furnished to Individuals Pursuant to U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act Form 398. This Information is maintained in. a system of records who supply information to the U.S. Nuclear Regulatory. Commission on NRC

designated as NRC 16 and described at 46 Federal Register 46717 (September 21,19811.

amended (42 U.S.C. 2137 and 2201 (1)).

1. AUTHORITY. Section 107 and 161(l) of the Atomic Energy Act of 1954, asfor determining licensing eligibility and to generate statistical data and

2. PRINCIPAL

PURPOSE

S. The Information will be collected and. evaluated reports on licensing actions.

if the individual meets the requirements of 10 CFR Part 55 to

3. ROUTINE USES. Information entered on this form may be used to: (a) determine evaluations related to selection, training, and examination be issued an operator's license; (b) provide researchers with Information for statistical management with sufficient Information to enroll the individuals in the licensed operator requalification of facility operators; (c) provide facility contractors.

program; (d) provide for examination and testing material and obtain results from

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION:

However, If the Information requested Is not provided, NRC will not be able to evaluate whether the applicant meets the Disclosure Is voluntary.

requirements of 10 CFR Part 55.

S. SYSTEMS MANAGERS AND ADDRESSES:

Regional Administrator, Region I Regional Administrator, Region 11 Chief, Operator Licensing Branch Commission U.S Nuclear Regulatory Commission Division of Human Factors Safety U.S. Nuclear Regulatory

631 Park Avenue 101 Marietta Street, Suite 3100

Office of Nuclear Reactor Regulation 19406 Atlanta, GA 30303 U.S. Nuclear Regulatory Commission King of Prussia, PA

Washington, DC 20555 Regional Administrator, Region IV Regional Administrator, Region V

Regional Administrator, Region Ill Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory

611 Ryan Plaza Drive, Suite 1000 1450 Maria Lane, Suite 210

799 Roosevelt Road Walnut Creek, CA 94596 Glene Ellyn, IL 60137 Arlington, TX 76011

p- V U_.

10 CER 55.10 Twerps. s - A - A.^ .............................. l^AjA.l ........ s NFIC. Formn2981' US. NUCI,/RE0ULATORY COMMISSION ._JApproved by OMB DATE RECEIVED (re Co*pIDr

3150.00901y IVRO) (AA)

0

o - 58.10

ANE 58.33 . PERSONAL QUALIFICATIONS STATEMENT-LICENSEE

1. APPLICANT'S FULL NAME fLatr fit, middtle) (AB) 4. TYPE OF APPLICATION l-"Xapp-lcdble boxes) (AHI

a. NEW a. REAPPLICATION

ADDRESS OR RFD NUMBER (AC) _ -HOT 1-FIRST

2-COLD 2-SECOND

CITY (ADI ISTATE(AE)IZIP CODE IAF) b. RENEWAL 3-THIRD

_A REAPPLICATION WAIVER REQUESTED

-- C. UPGRADE fI. if an reere

2. CITIZENSHIP JAG) 3. BIRTH DATE IAGI d. MULTI-UNIT -ORAL

a. UNITED STATES MONTH DAY

2-WRITTEN (CtWegory . . .

b. OTHER (Specify) I I I I 3-SIMULATOR

5. TYPE OF LICENSE APPLIED FOR JAI)

S. PREVIOUS LICENSEISI HELD Al) -I

a. OPERATOR a. DOCKET NUMBER b LICENSE NUMBER lMONTH RDAYTAION R l d. FACILITY DOCKET NUMBER

b. SENIOR OPERATOR 56 C. LIMITED SROb*.g. Fuel Handler)

Ad INSTRUCTOR CERTIFICATION

7. NAME OF APPLICANT'S EMPLOYER (AKM

I

10. CURRENT POSITION AT FACILITY (AS)

_ . PLANT SUPERINTENDENT I. AUXILIARY UNIT OPERATORI

ADDRESS IAL) ITRAINEE/TURBINE BUILDING/

b. ASSISTANT PLANT SUPERINTENDENT EQU

IPMENT OPERATOR

_ INONIJCENSED OPERA TORi c. SHIFT SUPERVISOR

CITY (AM) ISTATEIANI IZIPCODE (AOl d. STAFF ENGINEER ). OTHERISpciW .

I a. SHIFT TECHNICAL

_ ADVIOADVISOR/SHIFT ENGINEER _

S. NAME OF APPLICANT'S FACILITY (API FACILITY DOCKET f. INSTRUCTOR

IN Ag. SENIOR CONTROL ROOM

9. ADDITIONAL FACILITY DOCKETS fMulti-Unit LkenJj JARI OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION (AT)

a. HIGH SCHOOL C. MAJOR AREA(S) OF STUDY N UMBER HIGHEST DEGREE CODES tTo be used d. VOCATIONAL/TECHNICAL NUMBER

__ _ _ __

__ _ __ _Y__ EARS DEGREE fo, "HIGHEST DEGREE" CERTIFI.

GRADUATE ENGINEERING

_ _ _ _ __ _ _ _ _ _ F MONTHS

O__ CATE REC'C

fiel) (Usecode ob oiMsned.) TYPE OF TRAINING YES No

_ EO EQUIVALENCY 0-NONE

_ OTHER: ITE-CERTIFICATE

b. NUMBER OF YEARS

2-ASSOCIATE

OF COLLEGE 3-BACHELOR

4-MASTER

B-DOCTORAL

12. TRAINING (AU)

13. EXPERIENCE (AV)

a. MONTH AND YEAR NUMBER b. l . MONTH AND YEAR b.NUMBER

FROMl To TO

FROM TO OMMONTHS

1-NUCLEAR POWER PLANT FUNDAMENTALS

NAVY

sa esIro om i I 1- R

2-PLANT SYSTEMS

2-E2OWlPPWO

CLASSROOM 3-EWS/PPWS

OBSERVATION 4-ERS/CRW

3-OPERATING PRACTICE

B-OTHER (Specify)

CONTROL ROOM OPERATIONS FOSSIL

SIMULATOR OPERATIONS (Includes Classroom) 6-OPERATOR

SIMULATOR NAMEISS 7-SUPERVISOR

A-PLANT STAFF

CERTIFICYES N 9-OTHER (Specify)

N

ERECEI D

NT

U MBE OFNREACLTI N COMM ERCIAL NUCLEA R (including Research/TesI

4- SRO INSTRUCTION

Reactor)

4SOISRCIN 10-REACTOR

OPERATOR

-- EXTRA PERSON ON SHIFT

11-SENIOR OPERATOR

6-REO UALIFICATION

12-SHIFT SUPERVISOR

7-OTHER (Specify)

13-STAFF/SHIFT ENGINEER

1.4-AUX.IEQUIP. (NONLICENSEDI OPERATOR

15-PLANT STAFF

16-OTHER (Specify)

• -Z

-I -- I - - I-I

-- -~..- .... -.-.. 14. EXPERIENCE DETAILS (AW)

a. POSITION TITLE, - - , FACILITY c. DUTIES

15. COMMENTS [.pedfy the Ions number to i*hch you amlelaboratrnt)

POW NRC USE I* MEETS; REQUIREMENTS DOES NOT MEET REQUIREMENTS

15. NRC FOAM 398. CERTIFICATE. OF MEDICAL EXAMINATION 4AXI . .a. IS ATTACHED bs.WILL BE FORWARDED

17a. I certify'that the Informaiton provldsd.in this foria J&true and correct to the best of my knowledge. I also authorize the NRC to submit the results of axamlnetlons to my employer for urn in preparing retraining programs. as: nscessary.,

... .. . ,.INATU~t - APPLICANT I DATE

b. I certlf V that the above named individual hasor wIll hae"completed by the time of examination all the required training and haslearned to operate the controls In a competent and sefe manner pursuant to Title 10. Code of Federal Regulations. Pert 55; and that the Individual hasa need for an Operator/Senior Operator license to perform his/her assigned duties. I also certIfy that the facIllty will be made avallablp.1gr esarnjfelon..

IGAUE-TRAINING COOROINA~TOR

SIGNATUE DT

DATEFOR SIGNATURE- HIGHEST LEVE

PLANT CORPORATE MANAGEMENT

OPERATION DT

DT

c. RENEWAL ONLY.I. certify that the abovenamed Indivdual has satisfactorily completed the approved requalification program as required by section 50.54(1-I) of 10 CFR 50. and that s/he hasdischarged hls/hef.Ilcsnsofresprnlob~ltlascompwteftly and safely. ...

'4 .*.s -

t._ .SIGNATURE - TRAINING COORDINATOR _ I DATE I SIGNATURE - ~~ MANAUEFAVIT DATE

NRC FPrai9ns

~

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