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, 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, Crane
Issue date:	02/24/1983
From:	Eisenhut D G Office of Nuclear Reactor Regulation
To:
References
GL-83-012, NUDOCS 8302250505
Download: ML031080503 (4)

FEB 2 4 1983TO ALL POWER AND NONPOWER REACTOR LICENSEES, APPLICANTS FOR AN OPERATINGLICENSE, HOLDERS OF CONSTRUCTION PERMITS AND NSSS VENDORS(GENERIC LETTER -83-12)Gentlemen:Subject: Issuance of NRC Form 398 -Personal QualificationsStatement -LicenseeEnclosed is a copy of the new NRC Form 398 -Personal QualificationsStatement Licensee. This form must be submitted by all applicants foroperator and senior operator licenses under 10 CFR 5Find applicants forinstructor certificates. No other information or documents are requiredbeyond that which is requested in the instructions and the form itself.Please read all instructions carefully before completing this form. Notethat 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 398beginning no later than one-month from the date of this letter. To insurethat our records are complete and accurate, we request that the Initialsubmittal of Form 398 by an applicant be completed with respect to all infor-mation requested. Subsequent submittals of Form 398 require completion onlyof that information that has chanqed since the previous submittal of thisform, per the instructions provided. Questions regarding proper completionand usage of Form 398 should be directed to your appropriate Regional orHeadquarters Operator Licensing Branch staff.Requests for Form 398 should be directed to Vivian Miller, Nuclear RegulatoryComnission, Document Management Branch, M.S. W-548, Washington, DC, 20555.Allow two weeks for delivery. Copies of this form can be duplicated, ifnecessary.This request for information was approved by the Office of Manageipent andBudget under clearance number 3150-0090, which expires on August 31, 1985.Sincerely,Darrell G. Eisenhut, DirectorX Q2 52 Division of LicensingEnclosures: XZ4 Qfac4kjNRC Form 398 VPersonal Qualifications S tement -LFFens.eOFFICE Lcne ................ W........ ... ...k .~.N ................... ........ ........................ ......... ........ ....... ......r......... .SURNAMED ........ .. .........i .......... .............. ........ ........................ ........................ ..;......enDATE .. ./.. .....83 ..2.. ... ........................ ............. ........................ ........................URCFORM318 4 OFFI IAL RECORD COPY USGPO: 1981-335-960

,-,. J l-~INSTRUCTIONS FOR COMPLETION OFi NRC FORM 398, PERSONAL QUALIFICATIONS STATEMENT- LICENSEENEW APPLICANTS: Complete each category of the form completely, following the instructions below.RENEWAL, UPGRADED, MULTI-UNIT, AND REAPPLICATION APPLICANTS: Complete all Information that has changed since your previoussubmittal of an NRC Form 398. In addition, be sure to complete the following information:I -YOUR FULL NAME 5-TYPE OF LICENSE APPLIED FOR4-TYPE OF APPLICATION 6- PREVIOUS LICENSES AND/OR DOCKET NUMBER HELDSPECIFIC INSTRUCTIONS FOR ITEMS 11 -17:11 -EDUCATION: Indicate both academic and vocational/technical post high school education. For MAJOR AREA(S) OF STUDY, Indicatethe number of years spent In each collere curriculum and the highest degree received, using the degree code provided. For VOCATIONALJTECH-NICAL education, Include programs such as nuclear power school, military training, air conditioning/refrigeration, diesel mechanic school, etc. In-dicate the number of months in each program and whether a certificate or degree was awarded. If additional space is needed, continue under ITEM 15.12 -TRAINING: In this item indicate the training you have received to meet the requirements of ANSI N18.1/ANS 3.1. The breakdown oftraining in this category parallels the ANS standards: please refer to the standards If you need further clarification. Include both beginning and com-pletion dates and the total number of weeks spent in each type of training. NUMBER OF WEEKS is provided, in addition to beginning and comple-tion dates, to account for Intermittent training Ifor example, four weeks of classroom training spread over a two month period). Therefore, the datecolumns.may Indicate a larger time span than the actual number of weeks spent in full-time training.All requalification training time Is to be accounted for in the REQUALIFICATION item. Please avoid "double listing" recording all time spentin requallficatlon training under item 12.6, REQUALIFICATION, even though It may include classroom or simulatortime.13 -EXPERIENCE: For each position held, complete item 14.14 -EXPERIENCE DETAILS: Include position title, facility, and a brief description of duties performed while serving In that position. If morespace Is needed, use item 15, or if necessary attach additional information.15 -COMMENTS: Use this space to include any extra information or clarification for other items on the application form. If the space providedis not sufficient, you may attach extra Information with your application.16 -NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION: Include a completed NRC Form 396 with each application In orderto limit delays in issuing licenses. If this Is not possible, place an "X' in Item 16b, and forward the form as soon as possible: make sure all items arecompleted.17 -SIGNATURES: Sign and date item 17a. Obtain your Training Coordinator's signature and that of your highest level of corporate man-agement for plant operations.DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398, IN TRIPLICATE AND 396 TO:Branch Chief, Operator Licensing Branch or the appropriate Regional Administrator.PRIVACY ACT STATEMENTPursuant to U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following is furnished to Individualswho supply information to the U.S. Nuclear Regulatory. Commission on NRC Form 398. This Information is maintained in. a system of recordsdesignated as NRC 16 and described at 46 Federal Register 46717 (September 21,19811.1. AUTHORITY. Section 107 and 161(l) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2137 and 2201 (1)).2. PRINCIPAL

PURPOSE

S. The Information will be collected and. evaluated for determining licensing eligibility and to generate statistical data andreports on licensing actions.3. ROUTINE USES. Information entered on this form may be used to: (a) determine if the individual meets the requirements of 10 CFR Part 55 tobe issued an operator's license; (b) provide researchers with Information for statistical evaluations related to selection, training, and examinationof facility operators; (c) provide facility management with sufficient Information to enroll the individuals in the licensed operator requalificationprogram; (d) provide for examination and testing material and obtain results from contractors.4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION:Disclosure Is voluntary. However, If the Information requested Is not provided, NRC will not be able to evaluate whether the applicant meets therequirements of 10 CFR Part 55.S. SYSTEMS MANAGERS AND ADDRESSES:Chief, Operator Licensing Branch Regional Administrator, Region I Regional Administrator, Region 11Division of Human Factors Safety U.S. Nuclear Regulatory Commission U.S Nuclear Regulatory CommissionOffice of Nuclear Reactor Regulation 631 Park Avenue 101 Marietta Street, Suite 3100U.S. Nuclear Regulatory Commission King of Prussia, PA 19406 Atlanta, GA 30303Washington, DC 20555Regional Administrator, Region Ill Regional Administrator, Region IV Regional Administrator, Region VU.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission799 Roosevelt Road 611 Ryan Plaza Drive, Suite 1000 1450 Maria Lane, Suite 210Glene Ellyn, IL 60137 Arlington, TX 76011 Walnut Creek, CA 94596 p-V U_.10 CER 55.10Twerps. s -A -A.^ .............................. l^AjA.l ........ sNFIC. Formn2981'0 o -58.10ANE 58.33 .US. NUCI,/RE0ULATORY COMMISSIONPERSONAL QUALIFICATIONS STATEMENT-LICENSEE._JApproved by OMB DATE RECEIVED (re Co*pIDr3150.00901y IVRO) (AA)1. APPLICANT'S FULL NAME fLatr fit, middtle) (AB) 4. TYPE OF APPLICATION l-"Xapp-lcdble boxes) (AHIa. NEW a. REAPPLICATIONADDRESS OR RFD NUMBER (AC) _ -HOT 1-FIRST2-COLD 2-SECONDCITY (ADI ISTATE(AE)IZIP CODE IAF) b. RENEWAL 3-THIRD_A REAPPLICATION WAIVER REQUESTED--C. UPGRADE fI. if an reere2. CITIZENSHIP JAG) 3. BIRTH DATE IAGI d. MULTI-UNIT -ORALa. UNITED STATES MONTH DAY 2-WRITTEN (CtWegory ...b. OTHER (Specify) I I I I 3-SIMULATOR5. TYPE OF LICENSE APPLIED FOR JAI) S. PREVIOUS LICENSEISI HELD Al) -Ia. OPERATOR a. DOCKET NUMBER b LICENSE NUMBER l MONTH RDAYTAION R l d. FACILITY DOCKET NUMBERb. SENIOR OPERATOR 56C. LIMITED SRO b*.g. Fuel Handler)Ad INSTRUCTOR CERTIFICATION I7. NAME OF APPLICANT'S EMPLOYER (AKM 10. CURRENT POSITION AT FACILITY (AS)_ .PLANT SUPERINTENDENT I. AUXILIARY UNIT OPERATORIITRAINEE/TURBINE BUILDING/ADDRESS IAL) b. ASSISTANT PLANT SUPERINTENDENT EQU IPMENT OPERATOR_ INONIJCENSED OPERA TORic. SHIFT SUPERVISORCITY (AM) ISTATEIANI IZIP CODE (AOl d. STAFF ENGINEER ). OTHER ISpciW .I a. SHIFT TECHNICAL_ ADVIOADVISOR/SHIFT ENGINEER _S. NAME OF APPLICANT'S FACILITY (API FACILITY DOCKET f. INSTRUCTORIN Ag. SENIOR CONTROL ROOM9. ADDITIONAL FACILITY DOCKETS fMulti-Unit LkenJj JARI OPERATORh. CONTROL ROOM OPERATOR11. EDUCATION (AT)a. HIGH SCHOOL C. MAJOR AREA(S) OF STUDY N UMBER HIGHEST DEGREE CODES tTo be used d. VOCATIONAL/TECHNICAL NUMBER CERTIFI.__ _ __ _ __ _ __ _Y__ EARS DEGREE fo, "HIGHEST DEGREE" O__ _ _ _ _ __ _ _ _ _ _ F MONTHS CATE REC'CGRADUATE ENGINEERING fiel) (Use code ob oiMsned.) TYPE OF TRAINING YES No_ EO EQUIVALENCY 0-NONE_ OTHER: ITE-CERTIFICATEb. NUMBER OF YEARS 2-ASSOCIATEOF COLLEGE 3-BACHELOR4-MASTERB-DOCTORAL12. TRAINING (AU) 13. EXPERIENCE (AV)a. MONTH AND YEAR b. NUMBER l .MONTH AND YEAR b.NUMBERFROM TO l To FROM TO OM MONTHS1-NUCLEAR POWER PLANT FUNDAMENTALS NAVYsa e sIro o m i I 1 -R2-PLANT SYSTEMS 2-E2OWlPPWOCLASSROOM 3-EWS/PPWSOBSERVATION 4-ERS/CRW3-OPERATING PRACTICE B-OTHER (Specify)CONTROL ROOM OPERATIONS FOSSILSIMULATOR OPERATIONS (Includes Classroom) 6-OPERATORSIMULATOR NAMEISS 7-SUPERVISORA-PLANT STAFFCERTIFICYES N 9-OTHER (Specify)N EREC EI DNT U M BE OFN REACLTI N COM M ERCIAL NUCLEA R (including Research/T esI4- SRO INSTRUCTION Reactor)4SOISRCIN 10-REACTOR OPERATOR-- EXTRA PERSON ON SHIFT 11-SENIOR OPERATOR6-REO UALIFICATION 12-SHIFT SUPERVISOR7-OTHER (Specify) 13-STAFF/SHIFT ENGINEER1.4-AUX.IEQUIP. (NONLICENSEDI OPERATOR15-PLANT STAFF16-OTHER (Specify)*-Z --I -I --I-I

-- -.... ~..- -.-..14. EXPERIENCE DETAILS (AW)a. POSITION TITLE, --, FACILITY c. DUTIES15. COMMENTS [.pedfy the Ions number to i*hch you aml elaboratrnt)POW NRC USE I* MEETS; REQUIREMENTS DOES NOT MEET REQUIREMENTS15. NRC FOAM 398. CERTIFICATE. OF MEDICAL EXAMINATION 4AXI ..a. IS ATTACHED bs. WILL BE FORWARDED17a. 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 inpreparing retraining programs. as: nscessary.,... .. .,.INATU~t -APPLICANT I DATEb. I certlf V that the above named individual has or wIll hae" completed by the time of examination all the required training and has learned to operate the controls In a competent and sefe mannerpursuant to Title 10. Code of Federal Regulations. Pert 55; and that the Individual has a need for an Operator/Senior Operator license to perform his/her assigned duties. I also certIfy that thefacIllty will be made avallablp.1gr esarnjfelon..IGAUE-TRAINING COOROINA~TOR DT SIGNATURE- HIGHEST LEVE CORPORATE MANAGEMENT DTSIGNATUE DATEFOR PLANT OPERATION DTc. RENEWAL ONLY.I. certify that the above named Indivdual has satisfactorily completed the approved requalification program as required by section 50.54(1-I) of 10 CFR 50. and that s/hehas discharged hls/hef.Ilcsnsofresprnlob~ltlascompwteftly and safely. ...'4 .*.s -t._ .SIGNATURE -TRAINING COORDINATOR _I DATE I SIGNATURE -~~ MANAUEFAVITDATENRC FPrai9ns~ IV'43I -i,