Form 396 Certification of Medical Examination by Facility License

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390
NRC FORM 396

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0024

EXPIRES: 12/31/2008
Estimated burden per response to comply with this mandatory collection
request: 15 minutes. NRC requires this information to determine that the
physical condition and health of operator licensees is such that the applicant
would not be expected to cause operational errors endangering the public
health and safety. Send comments regarding burden estimate to the Records
Management Branch (T-5 F53), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by internet e-mail to [email protected], and
to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202,
(3150-0024), Office of Management and Budget, Washington, DC 20503. If a
means used to impose an information collection does not display a currently
valid OMB control number, the NRC may not conduct or sponsor, and a person
is not required to respond to, the information collection.

(4-2008)
10 CFR 55.21, 55.23,
55.25, 55.27, 55.31,
55.33, 55.57

CERTIFICATION OF MEDICAL EXAMINATION
BY FACILITY LICENSEE
NAME OF APPLICANT AND DOCKET NUMBER

FACILITY DOCKET NUMBER

FACILITY

050A. MEDICAL EXAM INFORMATION
THIS IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR/SENIOR OPERAT OR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN AND THAT THE APPLICANT HAS
BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS FOR LICENSE D OPERATORS AT THIS FACILITY.
STATE

PRINTED NAME (of physician and other medical professionals)

LICENSE NUMBER

MOST RECENT BIENNIAL MEDICAL
EXAMINATION DATE

BASED ON THE RESULTS OF THE PHYSICAL EXAMINATION, INCLUDING INFORMATION FURNISHED BY THE APPLICANT, THE PHYSICIAN HAS DETERMINED 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. I CERTIFY THAT IN REACHING THIS DETERMINATION, THE GUIDANCE CONTAINED IN THE ANSI STANDARD (AS ENDORSED BY THE APPLICABLE NRC REGULATORY GUIDE)
OR AN ACCEPTABLE ALTERNATIVE METHOD APPROVED BY THE NRC, AS INDICATED BELOW, WA S FOLLOWED, AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.

GUIDANCE USED:

ANSI/ANS 3.4 -- 1996

ANSI/ANS 3.4 -- 1983

ANSI/ANS 15.4 -- 1988 (Non-Power)

OTHER

ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN, IT IS REQUESTED THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS
FOLLOWS: Check all that apply. (PROVIDE EXPLANATION AND ATTACH SUPPORTING MEDICAL EVIDENCE FOR NRC REVIEW).

1. NO RESTRICTIONS
2. CORRECTIVE LENSES MUST BE WORN WHEN PERFORMING LICENSED DUTIES
3. HEARING AID MUST BE WORN WHEN PERFORMING LICENSED DUTIES
4. SOLO OPERATION IS NOT AUTHORIZED
5. MUST TAKE MEDICATION AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS
6. MUST SUBMIT MEDICAL STATUS REPORT EVERY

3,

6, OR

12 MONTHS

7. MUST NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR
8. OTHER RESTRICTION OR EXCEPTION
9. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL
10. INFORMATION ONLY
PROPOSED WORDING OF RESTRICTION (Block 8 above)

RELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION (Briefly indicate how restriction will correct the disqualifying condition)

EXPLANATION (S)

B. CERTIFICATION
ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF
PERJURY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRE CT.
SIGNATURE
PRINTED NAME AND TITLE (Senior Management Representative on Site)
DATE

In accordance with 10 CFR 55.5, Communications, this original form shall be sub mitted to the appropriate NRC office as follows: BY MAIL ADDRESSED TO:
REGIONAL ADMINISTRATOR, REGION I
U.S. NUCLEAR REGULATORY COMMISSION
475 ALLENDALE ROAD
KING OF PRUSSIA, PA 19406-1415

REGIONAL ADMINISTRATOR, REGION II
U.S. NUCLEAR REGULATORY COMMISSION
SAM NUNN ATLANTA FEDERAL CENTER
61 FORSYTH STREET, SW, SUITE 23T85
ATLANTA, GA 30303-8931

REGIONAL ADMINISTRATOR, REGION III
U.S. NUCLEAR REGULATORY COMMISSION
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352

REGIONAL ADMINISTRATOR, REGION IV
U.S. NUCLEAR REGULATORY COMMISSION
612 E. LAMAR BOULEVARD, SUITE 400
ARLINGTON, TX 76011-4125

U.S. NUCLEAR REGULATORY COMMISSION
OPERATOR LICENSING AND HUMAN
PERFORMANCE BRANCH
DIVISION OF INSPECTION AND REGIONAL SUPPORT
WASHINGTON, DC 20555-0001

RESEARCH AND TEST REACTORS
U.S. NUCLEAR REGULATORY COMMISSION
RESEARCH AND TEST REACTORS BRANCH B
DIVISION OF POLICY AND RULEMAKING
WASHINGTON, DC 20555-0001

NRC FORM 396 (4-2008)

PRINTED ON RECYCLED PAPER

INSTRUCTIONS FOR NRC FORM 396
CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE
Enter NAME OF APPLICANT, as it appears on NRC Form 398, and the applicant's DOCKET NUMBER.
Enter name of FACILITY(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 (i.e., 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 (i.e., 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 (i.e., the
applicant satisfies, without exception, all the criteria specified in the applicable ANSI standard).
Check 2. CORRECTIVE LENSES MUST 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 MUST 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. 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 5. MUST 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 6. MUST 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 7. MUST NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR if the applicant suffers from a respiratory
condition that would preclude the wearing of a respirator.
Check 8. 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 9. 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.
Check 10. 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.