Form NRC Form 398 NRC Form 398 Personal Qualification Statement - Licensee

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390
APPROVED BY OMB: NO. 3150-0090
EXPIRES: 11/30/2009
Estimated burden per response to comply with this mandatory collection request: 2.4 hours.
NRC requires this information to ensure that applicants/licensees meet all the requirements for
taking reactor operator examinations. Send comments regarding burden estimate to the
Records and FOIA/Privacy Services Branch (T-5 F52), 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, (3150-0090), 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.

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 398
(4-2008)
10 CFR 55.31, 55.35,
55.47, and 55.57

PERSONAL QUALIFICATION STATEMENT--LICENSEE
TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED
1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS (Include ZIP Code)

Mr.

Mrs.

4. TYPE OF APPLICATION (Check applicable boxes)

Ms.

f. WAIVER REQUESTED (Justify In Item 17)

a. NEW
b. RENEWAL

1 - WRITTEN

( Category

)

c. UPGRADE

2 - OPERATING ( Category

)

d. MULTI-UNIT (Amend to
Include Additional Unit)

3 - ELIGIBILITY
4 - MEDICAL

e. REAPPLICATION
2. CITIZENSHIP

MONTH

DAY

5 - OTHER

1 - FIRST DENIAL

3. BIRTH DATE

a. UNITED STATES

DATE RECEIVED
(To be completed by NRC)

g. DATE PASSED GFE

2 - SECOND DENIAL

YEAR

MM

3 - THIRD DENIAL

b. OTHER (Specify)

YY

4 - WITHDRAWAL

5. TYPE OF LICENSE APPLIED FOR

6. CURRENT OR PREVIOUS LICENSE(S) HELD

a. OPERATOR (RO)

a. DOCKET NO.

RO

SRO

LSRO

c. EXPIRATION DATE

b. LICENSE NUMBER

MONTH

DAY

YEAR

d. FACILITY DOCKET NUMBER

b. SENIOR OPERATOR (SRO)

050-

055-

c. LIMITED SRO (LSRO)

7. NAME AND ADDRESS OF APPLICANT'S EMPLOYER (Include ZIP Code)

10. CURRENT POSITION AT FACILITY

c. SHIFT SUPERVISOR

i. AUXILIARY UNIT OPERATOR/
TRAINEE/TURBINE
BUILDING/EQUIPMENT
OPERATOR (NONLICENSED OPERATOR)

d. STAFF ENGINEER

j. OTHER (Specify)

a. PLANT SUPERINTENDENT/MANAGER
b. ASSISTANT PLANT SUPERINTENDENT/MGR.

e. SHIFT TECHNICAL ADVISOR/SHIFT ENGINEER
FACILITY DOCKET NUMBER

8. NAME OF APPLICANT'S FACILITY

f. INSTRUCTOR
g. SENIOR CONTROL ROOM OPERATOR

9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
h. CONTROL ROOM OPERATOR

11. EDUCATION
a. HIGH SCHOOL

b. COLLEGE
MAJOR AREA(S) OF STUDY

GRADUATE
GED EQUIVALENCY
NO

ENGINEERING

OTHER

DEGREE CODES
(To be used for "HIGHEST
DEGREE" obtained)
HIGHEST
0 - NONE
NUMBER
DEGREE
OF YEARS (Use
1 - CERTIFICATE
Codes)
2 - ASSOCIATE
3 - BACHELOR
4 - MASTER
5 - DOCTORAL

c. VOCATIONAL/TECHNICAL

NUMBER
OF
MONTHS

TYPE OF TRAINING

CERTIFICATE
RECEIVED

YES

NO

12. POWER REACTOR OPERATOR TRAINING PROGRAM
a. HAS THE APPLICANT COMPLETED THE OPERATOR
TRAINING PROGRAM ACCREDITED BY THE
NATIONAL NUCLEAR ACCREDITING BOARD?

YES

NO

b. IS A "PLANT-REFERENCED SIMULATOR"
(AS DEFINED IN 10 CFR 55.4) USED IN THE
OPERATOR TRAINING PROGRAM?

13. TRAINING (Since Last Application - See Instructions)
a. CLASSROOM

MONTH AND YEAR
FROM

TO

DESCRIPTION

a.

2 -- PLANT SYSTEMS

b.

PLANT

SIMULATOR

c.

b. SIMULATOR

d.

c. SRO INSTRUCTION

e.

d. EXTRA PERSON ON SHIFT IN CONTROL ROOM

f.

e. TIME ON SHIFT ABOVE 20% POWER

g.

f. REQUALIFICATION

h.

g. OTHER (Specify)

NO

14. SIGNIFICANT CONTROL MANIPULATIONS
NUMBER
OF WEEKS

1 -- NUCLEAR POWER PLANT FUNDAMENTALS

3 -- PLANT PROCEDURES

YES

i.
j.

NRC FORM 398 (4-2008)

PRINTED ON RECYCLED PAPER

15. EXPERIENCE DETAILS
POSITION TITLE

FROM

TO

MONTHS

FACILITY

DUTIES

16. FOR RENEWALS ONLY
DATE

< 100 (LESS THAN)
a. HOURS OPERATED FACILITY:

100 - 1000
> 1000 (MORE THAN)

b. DATE AND RESULT OF LAST
WRITTEN COMPREHENSIVE
REQUALIFICATION EXAM AND
ANNUAL OPERATING TEST.

RESULT

W

PASS

FAIL

O

PASS

FAIL

17. COMMENTS

18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE, IS ATTACHED
19. SIGNATURES

ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a.

I certify under penalty of perjury that the information in this document and attachments is true and correct in accordance with the instructions. I further certify that I have notified
my current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HHS) Certified Drug Testing Laboratory or a
Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance where I
have been arrested for the sale, use, or possession of a controlled substance described in 10 CFR Part 26; and (4) any reasons for removal or revocation of unescorted access
at a nuclear facility. I also authorize the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
DATE
SIGNATURE - APPLICANT
CHECK APPLICABLE BOX FOR TYPE OF APPLICATION (i.e., check (b) if item 4.a, 4.c, 4.d, or 4.e is checked; check (c) if item 4.b, "RENEWAL," applies)
b. I certify that: (1) the above named individual has successfully completed the facility licensee's requirements to be licensed as an Operator/Senior Operator pursuant to Title
10, Code of Federal Regulations, Part 55; (2) the individual has a need for an Operator/Senior Operator license to perform his/her assigned duties; and (3) the facility will be
made available for the examination. I also certify under penalty of perjury that the information in this document and attachments is true and correct in accordance with
the instructions.
c. I certify that the above named individual completed the approved requalification program (with the exceptions noted in Item 17) required by section 50.54(i-1) of 10 CFR 50,
and that he/she has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information inthis document and
attachments is true and correct.
TRAINING COORDINATOR

SENIOR MANAGEMENT REPRESENTATIVE ON SITE

PRINTED OR TYPED NAME AND TITLE

PRINTED OR TYPED NAME AND TITLE

SIGNATURE

DATE

SIGNATURE

DATE

FOR NRC USE
WAIVER (Check or Complete items, as applicable)
CATEGORY

GRANTED BY
HEADQUARTERS

REGION

MEETS REQUIREMENTS

DOES NOT MEET REQUIREMENTS (Explain below)

DENIED BY
HEADQUARTERS

REGION

WRITTEN
OPERATING
ELIGIBILITY
MEDICAL
OTHER

SIGNATURE

DATE

INSTRUCTIONS FOR COMPLETING NRC FORM 398, PERSONAL QUALIFICATION STATEMENT--LICENSEE
You must complete items 1-10, 18, and 19, plus changes since your last applica tion, and other items as specified below. For
additional guidance refer to NUREG-1021, "Operator Licensing Examination Standa rds for Power Reactors," or NUREG-1478,
"Non-Power Reactor Operator Licensing Examiner Standards."
4. TYPE OF APPLICATION
a. NEW - "X" if you are a new applicant at this facility. Complete items 11-15 (10 CFR 55.31).
b. RENEWAL - "X" if you are renewing a current license. Complete items 12, 13.e, and 16 (1 0 CFR 55.57); if items 12.a and
12.b are checked "YES," then item 13.e does not have to be completed.
c. UPGRADE - "X" if you hold an RO license and are applying to upgrade your license to an S RO at the same facility.
Complete items 12, 13, and 15 relevant to the SRO upgrade.
d. MULTI-UNIT - "X" if you hold a license at your facility and are applying to amend your curre nt license to add an additional
unit. Complete item 13 as it applies to unit differences.
e. REAPPLICATION - "X" if you have previously been denied a license. Indicate whether you are r eapplying after a first denial,
second denial, or third denial. Describe, in detail, in items 13 and 17, the a dditional training completed since the last denial
(10 CFR 55.35). If you previously withdrew an application, check item 4.e.4 an d complete items 11-15.
f. WAIVER REQUESTED - "X" the applicable waiver requested and explain/justify in detail in item 17 (10 CFR 55.47). Refer to
NUREG-1021 or -1478, as applicable, for additional guidance.
g. DATE PASSED GENERIC FUNDAMENTALS EXAMINATION (GFE) - This is not applicable to research and test reactors or
licenses limited to fuel handling (item 5.c), renewal or upgrade applications ( items 4.b & c). Enter the month and year you
passed the GFE for the type of facility (BWR/PWR) identified in item 8. If you have not passed the GFE, explain in item 17.
11. EDUCATION - For college, enter the major area(s) of study, the number of years spent in eac h major area of study and the
highest degree obtained (using the degree codes listed on the form). For vocat ional/technical, enter the number of months
for each type of training and whether a certificate was awarded. If additional space is needed, use item 17.
12. POWER REACTOR OPERATOR TRAINING PROGRAM - Check the appropriate box in items 12.a and 12.b.
!
!

Checking "YES" in item 12.a indicates that you have completed a SAT-based train ing program that is accredited by the
National Nuclear Accrediting Board and meets the education and experience requi rements outlined by the National
Academy for Nuclear Training in its current guidelines for initial training and qualification of licensed operators.
If "YES" is checked in both items 12.a and 12.b then items 13 and 15 do not hav e to be completed with the following
exceptions: (1) certified instructors seeking an SRO license must complete item 15; (2) any exceptions or waivers from the
education and experience requirements outlined by the National Academy for Nucl ear Training must be explained in item 17.

13. TRAINING - All requalification training time is to be accounted for in item 13.e (unless items 12.a and 12.b are checked
"YES"). Do not "double list" the time spent in requalification training for cl assroom or simulator time under items 13.a or 13.b.
14. SIGNIFICANT CONTROL MANIPULATIONS - If you are a new applicant (item 4.a), you must provide evidence that you have
successfully manipulated the controls of the facility for which a license is so ught. Describe (date, time, type, and magnitude)
at least five significant control manipulations that affect reactivity or power level and whether the manipulations were
performed in the plant or on the simulator (10 CFR 55.31(a)(5), 10 CFR 55.46(c) ).
15. EXPERIENCE DETAILS - For each position held, provide position title, time in position (from/to and n umber of months),
facility, and a description of duties performed while in that position. Do not double count time. If you had overlapping duties,
the time should reflect the amount of time you were assigned to those particula r duties. In no case should the number of
months reported exceed the number of months that are in that time period. If more space is needed, use item 17 or attach
additional information.
16. FOR RENEWALS ONLY - (a) Check the box that most accurately reflects your approximate number of ope rating hours since
previous renewal or issuance of license if first renewal. (b) Enter the date a nd results of your most recent comprehensive
written requalification examination and annual operating test (10 CFR 55.57).
17. COMMENTS - Use this space to include any extra information or clarification for other item s on the application form. If the
space provided is not sufficient, you may attach extra information with your ap plication.
18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE, IS ATTACHED - NRC
Form 396 must accompany this application unless a waiver of the medical examina tion is being requested in item 4.f.4 (10
CFR 55.23).
19. SIGNATURES - You must sign and date item 19.a. Obtain signatures of your training coordinat or and your senior
management representative on site and have them check block 19.b or 19.c, as di rected (10 CFR 55.31, 10 CFR 55.57).
Detach these instructions and submit the completed original NRC Forms 398 and 3 96 to the appropriate address. (See
reverse side for addresses and for the Privacy Act Statement.)

ADDRESSES
In accordance with 10 CFR 55.5, Communications, this form shall be submitted to the appropriate NRC office 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
OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, DC 20555-0001

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

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following
statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 398.
This information is maintained in a system of records designated as NRC-16, described at 71 FR 59625 (October 10, 2006), or
the most recent Federal Register publication of the NRC's "Republication of Systems of Records Notices" that is located in
NRC's Agencywide Documents Access and Management System (ADAMS).
1. AUTHORITY: 42 U.S.C. 2137 and 2201(I).
2. PRINCIPAL PURPOSE(S): To ensure that applicants/licensees meet all the requirements for taking reactor operator
examinations.
3. ROUTINE USE(S): Information may be used to determine if the individual meets the requirements of 10 CFR part 55 to take
an examination or to be issued an operator's license; to provide researchers with information for reports and statistical
evaluations related to selection, training, and examination of facility operators; to provide examination, testing material, and
results to facility management. Information may be disclosed in accordance with any of the Routine Uses listed in the
Prefatory Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in the event
the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding.
In addition, this information may be transferred to an appropriate Federal, State, local and Foreign agency to the extent
relevant and necessary for an NRC decision about you. Information may also be disclosed, in the course of discovery under a
protective order issued by a court of competent jurisdiction, and in presenting evidence, to a Congressional office to respond
to their inquiry made at your request, or to NRC-paid experts, consultants, and others under contract with the NRC, on a
need-to-know basis.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING
INFORMATION: Disclosing this information is voluntary. However, if the information requested is not provided, NRC will not
be able to evaluate whether the applicant meets the requirements of 10 CFR part 55.
5. SYSTEM MANAGER(S) AND ADDRESS: Chief, Operator Licensing and Human Performance Branch, Division of Inspection
and Regional Support, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC
20555-0001.