ML20006D652

Discusses & Forwards Revised NRC Form 396,certification of Medical Exam by Facility Licensee & NRC Form 398,personal Qualifications Statement - Licensee

ML20006D652
Person / Time
Site:	05000134
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Newton T WORCESTER POLYTECHNIC INSTITUTE, WORCESTER, MA
References
NUDOCS 9002140173
Download: ML20006D652 (8)

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'JAN 5 1990 5

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Docke't'No:

50-134 3

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Worcester Polytechnic. Institute f

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ATTN:

Mr.-T. H. Newton,.Jr.

7 W2 Director Nuclear Reactor Facility i

TWorcester, Massachusetts' 01609-q n

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Gentlemeni j

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SUBJECT:

- REVISED NRC' FORMS 396 AND~398 r

L'.

Enclosed isia copy:ofithetrevised NRC Form-398 '(Enclosure 1), Personal.

'l Qual (fications Statement:- Licensee and revised NRC Form-396 (Enclosure 2),

?

! Certifdcation.of Medicalf Examination By Facility Licensee.

.All changes;to;the NRC Form-396 are detailed in Enclosure 3.

Changes to NRC U

. Form-398 are detailed in Enclosure 4.

iAll applications!for licenses. are to be submitted on these revised forms no-1

'later than' February 1, 1990~.

1 The enclosed: applications are for your use. Additional copies-can be obtained-by contacting,Beverly Martin, U.S; Nuclear Regulatory Commission, by telephone (301)4492-8138 or by: writing to her,-U.S._ Nuclear Regulatory Commission,

'Information and' Records Management Branch, Mail Stop NMBB 7714, Washington,

-D.C.-?20555.

i If you-have'any questions regarding these forms, please contact' Richard J.

_ a Conte at (215).337-5120 or Peter W. Eselgroth at (215) 337-5211.

+

i Sincerely, 1

5tBSes M1 1~

grisiD*1 M

Robert M. Gallo, Chief Operations Branch Division of Reactor Safety b

Enclosures:

As stated j

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'9002:40173 900105 PDR ADOCK 05000134 y

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0FFICIAL RECORD COPY 396 & 398 FORMS - 0063.0.0 l

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k, Worcester Polytechnic Institute 2

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Dr. R. Goloskie, Radiation Safety Officer Dr. J. C. Strauss, President-J. A. Mayer, Professor of Mechanical Engineering and Chairman, Nuclear Engineering Program Dr. William Vernetson, Director of Nuclear Facilities, University of Florida Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

F Commonwealth of Massachusetts (2) bec w/o enc 1:

Region'I Docket Room (with concurrences)

- Management Assistant, DRMA (w/o enc 1)

D. Haverkamp, DRP G. Grant,' SRI - Vermont Yankee L. Doerflein,1DRP OL Facility File i

DRS:RI Gallo/pb j

01/02/,9 g

,y;N V6 I OFFICIAL RECORD COPY 396 & 398 FORMS - 0064.0.0 12/14/89 L

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V INSTEUCTIONS POR COMPLETING NRC PORM MB -

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- PERSONAL QUALIFICATION STATEMENT-LICENBEE.

TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED i 4.'

TYPECF APPLICATION-

-- 2.e NEW "X" 1F YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COWLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS 15 TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE.

RECEIVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION. ALSO.T BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT TO "NEW."

l 2.b towv 2.e-FOR 2.b THRU 2.e COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION, NOTE: SEE ITEM f4 - TH RE IS AN EXCEPTION.

3 2.b RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE.

i 2.c UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYlNG TO UPGRADE YOUR LICENSE TO A SRO.

1 1

2.d MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR.

1 RENT LICENSE TO ADD AN ADDITIONAL UNIT, 2.e REAPPLICATION "X"lF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYlNG.

2.f WAIVER REQUESTED "X"THE APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

2.s DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES).

THl615 NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMIN TION SJCTION OF THE WRITTEN EXAMINATION WAS PASSED IF.THE GFESWAS NOTTAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES NOT INCLUDF INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

11 EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION, FOR MAJOR AREA {S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH' AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC.

INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREEWAS AW TlONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17),

x 12.

TRAINING - (NDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1. T BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS IF YO FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF

'lN EACH 7YPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR INTERMITTENT. TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2. MONTH

' PERIOD). THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL-TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED 1:OR CANNOT BE DOUBLE COUNTED EXPERIENCE (ITEM 13),

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE DO NO

- LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH lT MAY INCLUDE

. CLASSROOM OR SIMULATOR TIME.

13.

EXPERIENCE - A MINIMUM UF 6 MONTHS AT THE SIT E FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR 1

HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU HAD OVERLAPPING DUTIES, THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SH

- NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE TIME PERIOD.'

' 14.

FACILITY OPERATOR TRAINING PROGRAM - lNDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM; ANDb CERTIFIFO ION NRC FODH d7M OR NRC APPROVED ElMULATION FACILITY 10 VXD IN THE OPERATOR TRAINING PR GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14a AND 14.b, THEN ITEMS 11 (EDUCATIONI,12 (TRAINING),13 (EXFERIENCE),

AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED NEW APPLICATIONS MUST STILL INCLUDE THE OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3 NOTE: INPO ACCREDITED MEANS ACCREOITATION NATIONAL' NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REG GUIDE 1.8,' REV. 2, ARE MET.

15; FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICAT NATIONJ L

f I'

16.

EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION IF MORE SPACE IS NEEDED, USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATION.

. 17.

COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA-TION.

18.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 19.

SIGNATURES - SIGN AND DATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOU MANAGEMENT REPRESENTATIVE ON SITE, DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EACH lm IPRIATE REGIONAL ADMINISTRATOR.

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~e PORIII 35 U.$.10UCLEAA etG AULATORY - - - -

APPROVS) OY OMS: NO 31904050 D*TE.JC W ED tt E KTIMES: 13142 (Te se spaguesser er MCA 19 0PR GSJt.to.2,.

g6AT, seus tt A7 OSTIMATED SURDEN PER RESPONSE TO COtrLY INf7H THl3 SNFORMAT ON COLLECTIOtt REQUEST: 2D HRS POfWWARD COMAdENTS REGARDING BURDkN ESTlMATE PEREONAL OUAllFICATION ETATEMENT-LICENW.E To THE igeFORMAftON AND RECORDS MANAGEaAENT DRANCH IP.630). U S. GeUCLEAR REGULATORY OOtustS.

SeON, WASHissOTON. DC 20606. AND TO THE PAPtfusORK ftEDUCTION PMOJECT (315040501. OFFICE OF MANAGE.

TO MthEAIN VAllu,THIS FORGE hEUST NOT BE ALTEMED MENT AND DVDOET. WASHINGTON,0C 20003.

1. APPLICA8fT'8 PULL NatEE (last, /Jrst, Aasme) AND ADDRESS Paciu.+ EIP OpcN)

4. TYPE OF APPLICATION (Queck empire 6Ar &cses)

1. HOT l

e. RE APPLICATION

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2. COLD l. F BRST 1stRITTENICesugesyl 2.OPERATiteO fCese b.RfNEWAL

3. THIRO 8Y#

4. UPORADE i

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3. E L SOltiLITY

d. MULTI. UNIT (AAff 40 TO INCLUDE ADOfTIONAL

4. MEDICAL

2. CIT 12ENSHIP

3. DIRTH DATE UNITI f

S.OTHER a UNITEO $TATES MONTH DAY YEAR

s. DATE PASSED OENERIC FUNDA.

MM YY MENT ALS E X AMINATION SECTION

b. OTHER ISneeMvl l

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LIF' A *FL eCAOL EJ

5. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSEtti HELD a OPERATOl'

e. DOCKET NUMetR RO BRO k LICENSE NUMSER

d. F ACILITY DOLKET NUMetR

,n k $ENIOR DPE 8tATOR I

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e. LIMITE D SRt i te a. Feet HaasurrJ l

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7. NAtlE AND AD'sRESS (Jncivele t/P Cbde) OF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT F ACILITY

a. PLANT SUPERINTENDENT L AUxsLIARY UN11 OPER.

1

. ATORITRAINGEITURSINE

b. AS$1ST ANT PLANT SUPERINTENDENT DUILDlNO/EO JIPMENT OPER ATOR (N DN & tCENS.

s. SHIFT SUPERVISOR TO OPf RA TOel IL STAF.P ENO4NEER

l. OTHtR f3sendt/l _..

8. NAmet OF APPLICANT'S P ACILITY F ACILITY DOCKET NUMSER a SHIFT TECHNICAL ADVISOR / SHIFT ENOletEER

f. INSTRUCTOR

9. ADDITIONAL F ACILif Y DOCKETS (48verdwaar & *easee' g SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPER ATOR

11. EDUCATION -

N R

9WSCHOOL

e. MAJOR AREAlti OF 4TUDY

.,,7,'"a

';72'l DEGREE CODES

d. VOCATIONAL / TECHNICAL f,

p?tGNYO GREE ~ebtesaedl

'*HO****G ORAnUATE ENGINE ERtNO t!!ELO3)

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0N OED EUJIVALENCY dERTIFICATE m

2. ASSOCIATE 3 8ACHELOR h NUM{ER OF

4. M AST E R gAn 0,P

6. DOCTOR AL

13. T RAINING (SINCC LAST APPL ICA TION - SEE INSTRUCTIONS)

13. E XPERIENCE (DO NOT DOUBLE COUNT-SEE INSTRUCTIONS) e.uoNYwaNoyeAm e uOleTHANDVEAR e esua, sea enou to o*.n a n s NAyy emOu to

'88 *** ' as ggg 1 -NUCLEAR POWER PLA NT FUNDAMENTALS rooneJ 1.RO 2 -PLANT SYSTEMS

. 2. EOOW/PPWO CLASSROOM

3. EWS/PPWS

. OBSERVATION

4. E RS/CRW 3-OPERATINO PRACTICE 5.OTHER (seec,4s CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING Isac4ases Cws,vems FOSSIL

@$y[p%#pf4p '~ j.7. SUPERVISOR 6.OPERATO R j

SIMULATOR NAMES h (h a

b.

[ [M[$ lhfN h B. PLANT STAF F EnYu [ou'e7:Yao l lYES l l.40 y : pgjpg 9 OTHER f3aeci4A

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a t oNs 4' Wyf 'p@,gp"E:;&

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COMMERCIAL NUCLEAR flacAdne Assearca/ Tear seectorJ 4 -SRO INSTRUCTION 10 REACTOR OPERATOR (themsedJ 5.hQagagO,N

,$Miei IN CONIMOL ROOu

11. SENIOR OPERATOR (twenents

= a. $'gy".s,gg,gva aos rowan 12 SHIFT SUPERVISOR (theaansi 6.REQUALIFICATION

13. STAFF / SHIFT ENGINEER (tkeaseas

? -OTHE R (3,ses&J g4. AUXJEQUIP. OPE R ATOR (Noaskeased)

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15. PLANT STAFF 16.OTHER tsoves&s l

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.14. FACILITY OPERATOR TRAINING PR00 RAM A CERTIFIED OW N FORM e)4 t"tMfMLA fh)4 #ACfL/TF G

OP08080AccR6tifs0OPSRATOR IIGS PMBORAas f eeAT SS SAGEn UFON A YES NO C'27Cd F808#

""C ^'rROVE0 SlMULAT90e8 YES NO '

f ACILITY 18 USED IN THE OPERATOR TRAlesteso 9W9tWS 40ph0AcM TO TRAsapees PsionaAed

16. FOR RENEWALS ONLY -

4 1

b. DATE AseO RESULT OF Moti.

DATE RUB /d i

teOUR6 0PORAT80 F ACILff y;-

R6CGNT NRC ADMINISTERED pAgg EA!b REQUALifICATION ERAMINATION

16. EXPERIENCE DETAILS sw POSITt00dTITLE PR0es 10

b. F ACILITY

e. DUTIES 1

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p. ODeestarTs masent sne m emneer so wome you em -

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18. 09AC pores 308. CERTIFICATION OF GABOICAL EMARAINATION SY P ACILITY LICENBEE;IS ATTACHED ANY F ALSE STATEMENT OR OMISSION IN THl8 DOCUMkhT. INCLUDING ATTACHMENTS. MAY BE SUts)ECT TO CIVIL AND CRIMINAL SANCTIONS.-

h i eenley unser penesty of portiery that the 6ntorenellon > ahte desumene end etteshmente le tvue snel seneet. I further sortify that 1 have notified my evnent emisseyer ef: til est pseuseus angeovers,

. (31 eny inseemse sehere 1 huge been egeted try e HesRh and Human torstose (HMEn Cortleted Drus Testing Lehoretary er e Lisonese's teettne lestegy ter Moshot er a sentseited estatense.enal the test

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senslee essanted the outeft levoeg enesteeened pusasent to 10 CPR Part 20; 136 any instanse vehese I have been ersessed for the emes. use er.

of a contrusted euheenes elegerthed in 10 CPR Part 24;

' and 446 eny sesenne ter semount er seineseten of unesserted essess et 8 musesertteelitty, I the authertse the feRC te submit the egeutte el enemiretions te my empseyere ter Wee en gesogr6ng retrein6ng e Seegness. Se B"*y SIGNATURE.AFPLICANT DATE I

CNECK APPLICABLE BOX i

b. I eartley tems the shoes mened indeeldual hee aussessfully commes,ted th,e fe,elitty leoneses,te,au6rements to he beensed es en Operatorteenior Operator pursuont to Thie 10. Code of Federes Repaistione,'

. I re Part Gat eed test etes endessesel has e need ter en r

,n goe see lies ge to pe m heether emeyed dutos and that tesew he susse sentesase ser esameneteen. 4 eeen eartify under posemy of pastery test the insennesten in thee desument and esternmente h tvue end sorrect.

Y 6 RONEWf AL ONS.Y. I eartify that the shove named individual meets the asesoved reinsellflession proerem Isrtra esseprinne nesseus from 77J es voeutved by emetion 50.64 ti al of 10 CFR 60.and.

that hetene hee dtscherges heether lleensed ressenedblenge componentry and ufety. I eleo certify under penetty of portury that the Intermeten in this document and ettschments.

h snm end ewrect.

3 s RAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE -

PRINT 80 OR TYPSD esAME PRINTED OR TYPED NAME lDATE seGN.:.TURE

&lONATURI DATE I

i FOR NRC USE I

WAlVE R (Check or Compiste # ems, es app #cabdel l ME ETS REQU4REMENT3 l l DOES NOT MEET REQUIREMENTS Issedede esewJ OnANTED e v DefeleD e v gggy HE ADQuARTe R$

R E GION HeADQUARTERE Mc GION ERITTEN OPERATING EL1T181LITY MEDICAL SlQNATURE-REVIEveER DATE OTHER-k$

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U s. NUCLE AA L50VLAf om y conseoesiom a.pe.oveojv ggmoenza

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Ta IN MATioN noN T

CERTIFICATION OF MEDICAL EXAMINATION gag o,,c,q=ll y,g,,a 'f,,aa cWo;'og,,,pl=

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o SY FAClUTY LICENSEE e.n ANC.H.19 43ol.

oC C.L.E.AR. ANo,uLAT,DA,Y,.C.o.saas.tS, US NU Rfo ion.

A. NoToN oT A

so ma pucTioN ruoaac 2inoco24 ossics oF MANaos.

MENT ANo eUpotT..t AswiNo7oN oc zonoa.

I NAME OF APf'LICAN T F ACILIT Y l F ActLITY 00' AET NUM8E R A. MEDICAL EXAMINATION CERTIFICATION THl315 TO CE RTIF V THAT THE ABOVE NAMED APPLICANT FOR At OPERATDR TENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.

E XAMIN ATION C ATE PalN T E D N AME (of shrsscant lST ATE AND LICENSE NUMBER BASED ON THE RESULTS OF THE EXAMINATlON. INCLUDING INFORMATION FURutSHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION ANL, GENE R AL HE ALTH ARE NOT SUCH THAT IT M10HT CAUSE OPERATION AL E RRORS ENDANGERING PUBLIC HE ALTH AND EAF E fY I CE RTIF Y THAT IN RE ACHING THis DETERMINATION. THE GUIDANCE CONT AINED IN ANSI /ANS 3 4-1983. OR ANSI /ANS 15 41977 (N3001 WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW 8Y NRC ON THE BASIS OF THE RECOMMENDATION OF ItMHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO RESTRICTIONS

7. CORRECTIVE LENSES 8E WORN WHEN PERFORMING LICENSED DUTIES

3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICENSE OR EXCEPTION Provute details below and attach suppurimg medical evulence for NRC review.

6. RESTRICTION CHANGE FROM PRE VIOUS SU8MITTAL Provide netails below and attach wooortmg medical evidence te NRC review.

PROPOSED WJRDING OF RESTRICTION (8/oca d anoves AE LATlONSHIP OF RESTRICTION TO DISOUALIF YING CONDifION (StreffP marote Aow rearr cTen w,dicorrect the Weapueldyme condiren)

RE MARKS FOR RESTRICTION CHANGE (SApca $ abovej I

B. NONMEDICAL CERTIFICAllON POWE R RE ACTORS.

THl5 CERTIFIES THAT THE APPLICANT HAS 8EEN FOUND TO MEET THE SAFEGUARD $' AND FITNESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPE R ATORS NON-POWE R RE ACTORS.

THl3 CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUAROS' REOulREMENTS OF THis F ACILITY FOR LICENSED OPERATOR 3. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISMED PURSUANT TO 10 CFR 26.

ANY e ALat 31 AT EMENT OH UMisslUN IN TMt3 DOCUMtNt. INCLUDiNO Af t ACHM(N IS MAY BE EUBJECT TO Civik AND GRIMiNAL SANGiiONS. I 4tH tie Y UNutM PkNALI V Ut itRJUHV THAT THE IN80mMATiON iN THis DOCUMENT AND ATT ACHMENTS 18 TRUE ANo CORR $CT.

PAINTED NAME AND SIGN ATURE (Senor Asanagement Neoreesnrarsee on S,tel TlTLE DATE in accoroance wun 10 CF R 55 5. Comenunicatens. tAs form snesi be submitted to the NRC as follows: SY MAIL ADORESSED TO; Regenet Admmntrator. Region t Regierut Adminestrator. Regen il Regional Adm.netfator. Regican ill U.S. Nuclear Regulatory Commnsen U.S. Nuclear Regulatory Commnsen U.S Nuclear Requietory Commissen 475 Alterutate Road 101 Marietta Street. Suite 3100 799 Roosevent Road King of Prussia, PA 19406 Atlanta GA 30323 Glen Eilyn. IL tiO131 1

Regenal Administrator Region av Regiones Admmntrator Region V U S. Nucwar Requiatory Communen U 1 Nuclea. Regulatory Commissen 611 Ryan Pina Onve. Suite 1000 1450 Maria Lane. Suite 210 Artmgeon. T X 16011 Walnut Creee. CA 94596 PRIV ACY ACT ST ATEMENT Purwant to 6 U.1C 552aleH3L enacted mio saw by wetion 3 of the Privacy Act of ROUTINE USES: The mformation may be disclosed to an appropnate Federal. State. or 1974 (Public Law 91519L the fo6aowmg statement is turnisned to moividuals eno local agency m the eveni the mtormation mdicates a vioeanon or potentesi veuten of law supply mformaten to the U.S Nuclear Hogulatory Commissen on NRC Form 396. and m the event the mformat.on mdicates a violaten or potential velaten of law and m This m'ormaten n maintained m a system of records designated as NRC-16 and the course of an admmntrative or tudecies proceedmq in addition. th,s mformaten may be described at 51 Faleral Register J3157 (September 18.1986L transferred to an appropredte Federat. State. and local agency to the entent relevant and AUTHORITY; Sections 107 and 161b) of the Atomic Energy Act of 1954. as necessary for an NRC decnion doout you.

amendad l42 U S.C. 2131 and 270lli)).

WHETHE R Di'iCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISI: Informaten entered on this lorm n used to determme INDIVIDUAL OF NOT PROVIDING INFORMATION Disclosure a voeuntary. If the l

wnether the pnysical conditeon and general health of the applicant are suen that they requested mformation is not provided. however, the appiecation for a facility operator's will not cause operatonas errors endangstmq puolic health and safety. This mforma or senior operator ilicense may be derhed ten may be used by the NRC staff to determ ne if the mdividual meets the require-SYSTEM MANAGERIS) AND ADDRESS Chief. Operator Licensmg Branch. Ottice of ments of to CF R 55 to taae en suammateon or to be usued an operator t license Nuclear Reactur Reipelaten. U.S. Nuclear Regulatory Commns.on. Washmgton. DC 20555 l

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D U 460RI 3 Sutts OF CHANGES 1015C 70Ett 398 Medical' Examination Certification AMarl block "Hestriction Change Free Prwious kinittal" plue Remarks section.

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Non-Medical Cortification Qianged nonW4=1 certificatica statement to: Ptmer Remotors-This certifies that the asqplicant has been found to meet the safeguards' and fitnese for drty requirements of this this facility for licensed operators.

Wr-this certifiae that the applicant has been found to meet the safeguards

• requirements of this.

facility for liaanaed operators and I have no knculedge of the applicart

--- ei4m the cutoff. levels for alanhal-or ocatrolled substanaan as estahlinhad pareuent to 10 CFR 26, i

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c EMC148WlE 4 StttRRY OF QWM510 450 PCIM 398 I%u 4.d Added clarifying statamast to indiosta this is to be i

chauted only if applination is to amend license to i

add additional unit (s).

[

Itsa 4.f Added "(Catasary)" to Cperating.

Added " Medical",

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{

Itas 4.s Added a neo item "Dete Passed Generic Fundamentals Exeadnation Section".

Item 12.3 Changed wording to " Certified Startup Program Completed" I

for clarification.

I 1

Item 12.5 mensed mos111ms to "Esten Passen On Shift In Control Room I

(13-usek minim a)" for clarificatica.

I Item 12.5a Added a neo item " Time h Riitt Above 205 Poser (6-9 seek mintaus)".

Item 14.a Added the words "That Is Bened Upon A Sreteos Approach to Training" for clarification.

Item 15 Added "Date and Result of Most Recent 190 Administered Requalification Emanimatka".

Item 19.a Added the wordias "I Aarther osetify that I have notified-ur einvent employer oft (1) all pawfous employers: (2) aar instaum whus I have base tested br a Health and Himeen Servions (NB) Certified Drug footing Laboratory or a Licensee's tasting facility for alcohol or a controlled substance, and the test resulta M the autoff levels established parsuant to 10 CFR Part 26: (3) anr instance where I have been arrested for the sale, use or possession of a controlled substanos described in 10 CFR Part 26: and.

(4) any reasons for removal or twooostian of uneeJorted aooses at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c toestbar. Applionhle bon mast now be checked. Also added block for typed nome of Training Coordinator and Senior Menessment Rapstaantative 2 Site.

P 3CR HRC USE Onder waiver estesosy added " Medical".

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