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

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390
U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 398
(MM-YYYY)
10 CFR 55.31, 55.35,
55.47, and 55.57

PERSONAL QUALIFICATION STATEMENT--LICENSEE
TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED
Mr.

Mrs.

✔

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0090

DATE RECEIVED
(To be completed by NRC)

Estimated burden per response to comply with this mandatory collection request: 4.8 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 FOIA,
Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by 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.

Ms.

4. TYPE OF APPLICATION (Check applicable boxes)

1. APPLICANT'S FULL NAME (Last, First, Middle)

a. NEW

1a. APPLICANT'S FULL ADDRESS (Include ZIP Code)

MONTH

a. UNITED STATES

DAY

1 - WRITTEN

( Category

)

c. UPGRADE

2 - OPERATING ( Category

)

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

3 - ELIGIBILITY

e. REAPPLICATION

4 - MEDICAL
5 - OTHER

1 - FIRST DENIAL

3. BIRTH DATE

2. CITIZENSHIP

f. WAIVER REQUESTED (Justify In Item 17)

b. RENEWAL

g. DATE PASSED GFE

2 - SECOND DENIAL

YEAR

MM

3 - THIRD DENIAL

b. OTHER (Specify)

YY

4 - WITHDRAWAL
6. CURRENT OR PREVIOUS LICENSE(S) HELD

5. TYPE OF LICENSE APPLIED FOR
a. OPERATOR (RO)

a. DOCKET NO.

b. SENIOR OPERATOR (SRO)
c. LIMITED SRO (LSRO)

RO

SRO

LSRO

b. LICENSE NUMBER

c. EXPIRATION DATE
MONTH

DAY

YEAR

d. FACILITY DOCKET NUMBER

050-

055-

10. CURRENT POSITION AT FACILITY

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

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.

8. NAME OF APPLICANT'S FACILITY

e. SHIFT TECHNICAL ADVISOR/SHIFT ENGINEER

FACILITY DOCKET NUMBER

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

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

HIGHEST
DEGREE

NUMBER
OF YEARS

(Use Codes)

ENGINEERING

OTHER

c. VOCATIONAL/TECHNICAL

NUMBER
CERTIFICATE
OF
RECEIVED
MONTHS

TYPE OF TRAINING

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

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

TO

NUMBER
OF WEEKS

DESCRIPTION

1 -- NUCLEAR POWER PLANT FUNDAMENTALS

a.

2 -- PLANT SYSTEMS

b.

3 -- PLANT PROCEDURES

YES

NO

14. SIGNIFICANT CONTROL MANIPULATIONS

MONTH AND YEAR
FROM

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

NO

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)

i.
j.

NRC FORM 398 (MM-YYYY)

Page 1

DOCKET NO.

APPLICANT'S FULL NAME:
15. EXPERIENCE DETAILS

(MM/DD/YYYY)
POSITION TITLE

FROM DATE

055-

TO DATE

DUTIES

FACILITY

MONTHS

16. FOR RENEWALS ONLY
< 100 (LESS THAN)
a. HOURS OPERATED FACILITY:

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

100 - 1000
> 1000 (MORE THAN)

DATE

RESULT

W

PASS

FAIL

O

PASS

FAIL

17. COMMENTS

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

Yes

No

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.

SIGNATURE - APPLICANT

DATE

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) th e 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 in this 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

SIGNATURE

DATE

DATE

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

HEADQUARTERS

MEETS REQUIREMENTS

REGION

HEADQUARTERS

DOES NOT MEET REQUIREMENTS (Explain below)

EXPLANATION(S)

DENIED BY

GRANTED BY

REGION

WRITTEN
OPERATING
ELIGIBILITY
MEDICAL
OTHER
NRC FORM 398 (MM-YYYY)

SIGNATURE

DATE
Page 2

INSTRUCTIONS FOR COMPLETING NRC FORM 398, PERSONAL QUALIFICATION STATEMENT--LICENSEE
You must complete items 1-10, 18, and 19, plus changes since your last application, and other items as specified below. For
additional guidance refer to NUREG-1021, "Operator Licensing Examination Standards 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.f, and 16 (10 CFR 55.57); if items 12.a and
12.b are checked "YES," then item 13.f does not have to be completed.
c. UPGRADE - "X" if you hold an RO license and are applying to upgrade your license to an SRO 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 current 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 reapplying after a first denial,
second denial, or third denial. Describe, in detail, in items 13 and 17, the additional training completed since the last denial (10
CFR 55.35). If you previously withdrew an application, check item 4.e.4 and 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 each major area of study and the highest
degree obtained (using the degree codes listed on the form). For vocational/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 training program that is accredited by the
National Nuclear Accrediting Board and meets the education and experience requirements 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 have 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 Nuclear Training must be explained in item 17.
13. TRAINING - All requalification training time is to be accounted for in item 13.f (unless items 12.a and 12.b are checked "YES").
Do not "double list" the time spent in requalification training for classroom 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 sought. 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)). If needed, use box 17 or attach information.

15. EXPERIENCE DETAILS - For each position held, provide position title, time in position (from/to and number 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 particular 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 operating hours since
previous renewal or issuance of license if first renewal. (b) Enter the date and 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 items on the application form. If the
space provided is not sufficient, you may attach extra information with your application.
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 examination 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 coordinator and your senior
management representative on site and have them check block 19.b or 19.c, as directed (10 CFR 55.31, 10 CFR 55.57).
Detach these instructions and submit the completed original NRC Forms 398 and 396 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
2100 RENAISSANCE BOULEVARD, SUITE 100
KING OF PRUSSIA, PA 19406-2713

REGIONAL ADMINISTRATOR, REGION II
U.S. NUCLEAR REGULATORY COMMISSION
245 PEACHTREE CENTER AVENUE, NE., SUITE 1200
ATLANTA, GA 30303-1257

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
1600 E. LAMAR BOULEVARD
ARLINGTON, TX 76011-4511

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

PRIVACY ACT STATEMENT
NRC FORM 398
PERSONAL QUALIFICATION STATEMENTLICENSEE
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 as part of a system of records designated as NRC-16, described at 77 FR 67214 (November 8, 2012), or the most recent
Federal Register publication of the NRC's "Republication of Systems of Records Notices" that is located in NRCs Agencywide
Documents Access and Management System (ADAMS).
1. AUTHORITY: 42 U.S.C. 2131-2141; 10 CFR Part 55.
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 operators 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 to an appropriate Federal, State, local or Foreign agency in the event the information indicates a
violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local
and foreign agency to the extent relevant and necessary for an NRC decision about you; 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; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to
appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data
from this system of records.
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 Training Branch, Division of Inspection and Regional
Support, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.