Form 396 Form 396 Certification of Medical Examanation by Facility License

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390
NRC FORM 396
(MM-YYYY)
10 CFR 55.21, 55.23,
55.25, 55.27, 55.31
55.33, 55.53, 55.57.

U.S. NUCLEAR REGULATORY COMMISSION

APPROVED BY OMB: NO. 3150-0024

CERTIFICATION
OF MEDICAL EXAMINATION BY
FACILITY LICENSEE

Estimated burden per response to comply with this mandatory collection request: 30 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 Information Services
Branch (T-2F43), 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, (3150-0024),
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.

Name of Applicant/Operator

Applicant/Operator Docket Number

Full Address of Applicant/Operator

Facility

EXPIRES: (MM/DD/YYYY)

Date of Most Recent Biennial Examination (MM/DD/YYYY)

Facility Docket Number

050052A. MEDICAL EXAM INFORMATION
BASED ON THE RESULTS OF THE PHYSICAL EXAMINATION, INCLUDING INFORMATION FURNISHED BY THE APPLICANT/
OPERATOR, I CERTIFY THAT THE ABOVE NAMED APPLICANT/OPERATOR HAS BEEN FOUND TO MEET THE MEDICAL
REQUIREMENTS FOR LICENSED OPERATORS AT THIS FACILITY. I ALSO CERTIFY THAT IN REACHING THIS DETERMINATION,
THE GUIDANCE CONTAINED IN THE ANSI STANDARD OR AN APPROVED NRC ALTERNATIVE METHOD WAS FOLLOWED AND
THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY THE NRC.
GUIDANCE USED:
ANSI/ANS 3.4 -- 1983

ANSI/ANS 3.4 -- 2013

ANSI/ANS 15.4 -- 2007

ANSI/ANS 3.4 -- 1996

ANSI/ANS 15.4 -- 1988

ANSI/ANS 15.4 -- 2016

Typed or Printed Name of Physician

Physician's Certification Date (MM/DD/YYYY)

State

Other (Specify below)

License Number

BASED ON THE RECOMMENDATION OF THE PHYSICIAN, IT IS REQUESTED THAT THE APPLICANT/OPERATOR LICENSE BE
CONDITIONED AS FOLLOWS: Check all that apply. PROVIDE EXPLANATION IN BOX BELOW AND ATTACH APPLICABLE
SUPPORTING MEDICAL EVIDENCE (letter from the examining physician outlining the condition, treatment and or medication
(name, dose, timing & tolerance) and medical examination/ test results (current blood pressure reading, A1C, TSH levels, etc.)
1.

NO RESTRICTIONS

2.

CORRECTIVE LENSES SHALL BE WORN WHEN PERFORMING LICENSED DUTIES

3.

HEARING AID SHALL BE WORN WHEN PERFORMING LICENSED DUTIES. THIS DOES NOT APPLY TO CONDITIONS THAT
REQUIRE PROTECTION IN HIGH NOISE AREAS.

4.

SHALL TAKE MEDICATION AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS

5.

SHALL USE THERAPEUTIC DEVICE(S) AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS

6.

SOLO OPERATION IS NOT AUTHORIZED

7.

SHALL SUBMIT MEDICAL STATUS REPORT EVERY:

8.

SHALL NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR

9.

OTHER RESTRICTIONS OR EXCEPTION

3

6

12 months, or

Other

10. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL
11. INFORMATION ONLY
NRC FORM 396 (MM-YYYY)

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

NRC FORM 396
(MM-YYYY)

CERTIFICATION OF MEDICAL EXAMINATION
BY FACILITY LICENSEE (continued)
Docket Number

Name of Applicant/Operator

Proposed Wording of Restriction (Block 9 on page 1)

Relationship of Restriction to Disqualifying Condition (Briefly indicate how restriction will correct the disqualifying condition)

Explanation(s)

B. APPLICANT/OPERATOR'S SIGNATURE

I acknowledge the information in this certification and attachments as they apply to my licensure by the NRC. I authorize
my facility to provide this certification and attachments to the NRC to use in the exercise of its authority over my licensure.
Signature

Date

C. FACILITY CERTIFICATION
I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
Printed Name and Title of Senior Management Representative
Signature

NRC FORM 396 (MM-YYYY)

Date

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NRC FORM 396
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE (Instructions)

Enter NAME OF APPLICANT as it appears on NRC Form 398 or NAME OF OPERATOR as it appears on the NRC issued License, DOCKET NUMBER
and DATE OF MOST RECENT BIENNIAL MEDICAL EXAMINATION. If the time since the applicant's initial medical examination exceeds 24 months
before an initial licensing action is completed, the applicant must be reexamined by a physician and a new NRC Form 396 must be submitted. For retake
and upgrade applicants whose medical examinations do not exceed 24 months, the facility must check Box 12.c.3 and certify in Box 25 on the NRC Form
398 that applicant has not developed any disqualifying medical conditions reportable under 10 CFR 55.25. If, during the term of the license, an operator
develops a permanent physical or mental condition that causes the operator to fail to meet 10 CFR 21 that can be mitigated by requesting a license
restriction, the facility licensee shall notify the NRC within 30 days of learning of the diagnosis by submitting an NRC Form 396. 10 CFR 55.25 requires a
submission for only permanent conditions. Do not submit temporary conditions for which an operator is being administratively held by your facility. Per 10
CFR 55.55, NRC Operator license renewals (NRC Form 396 and NRC Form 398) shall be submitted at least 30 days prior to the license expiration date.
Enter ADDRESS OF APPLICANT/OPERATOR
Enter NAME OF FACILITY(IES) and FACILITY DOCKET NUMBER(S) - Use Check Box to indicate 050-XXX or 052-XXX.
Use Check Box to indicate which Guidance Document (ANSI 3.4, 15.4 or other) was used to determine the applicant's physical condition. If other is
checked, include the title of the document.
SECTION A - MEDICAL EXAM INFORMATION - Enter PHYSICIAN'S PRINTED NAME, PHYSICIAN'S CERTIFICATION DATE, LICENSE NUMBER,
AND STATE OF LICENSURE. (Indicate MD or OD following printed name).
License Conditions - Use numbered Check Boxes to request license condition(s).
Box 1 - NO RESTRICTIONS - Physical and mental condition and general health meet the minimum requirements, without exception.
Box 2 - CORRECTIVE LENSES SHALL BE WORN WHEN PERFORMING LICENSED DUTIES - Corrective lenses must be worn to meet the minimum
requirements for vision.
Box 3 - HEARING AID SHALL BE WORN WHEN PERFORMING LICENSED DUITES - Hearing aid must be worn to meet the minimum requirements.
Box 4 - SHALL TAKE MEDICATION AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS - Meets the minimum medical requirements only by
taking prescribed medication(s).
Box 5 - SHALL USE THERAPEUTIC DEVICE(S) AS PRESCRIBED TO MAINTAIN MEDICAL QUALIFICATIONS - Meets the minimum medical
requirements only by using a therapeutic device (e.g., CPAP and Spinal Cord Stimulator).
Box 6 - SOLO OPERATION IS NOT AUTHORIZED - Another individual, capable of summoning help must be present when the operator is performing
licensed duties.
Box 7 - SHALL SUBMIT MEDICAL STATUS REPORT EVERY 3, 6 , 12 or Other Months - Medical condition that requires more frequent monitoring than
the two (2) years required by 10 CFR 55.21. If Other is checked, include the requested time frame.
Box 8 - SHALL NOT PERFORM LICENSED DUTIES REQUIRING A RESPIRATOR - Respiratory or integumentary (skin) condition.
Box 9 - OTHER RESTRICTIONS OR EXCEPTION - Other license condition(s) necessary to mitigate identified medical or psychological issue(s) that do not
meet minimum medical requirements. Use "Proposed Wording of Restriction" and "Relationship of Restriction to Disqualifying Condition" boxes.
For all but Check Boxes 2 and 3, supporting Medical Evidence must include a narrative in the Explanation box or an attached letter from the examining
physician outlining the condition, treatment and or medication (name, dose, timing & tolerance) and medical examination/test results (current blood pressure
reading, A1C, TSH levels, etc.), for NRC review. If an applicant or operator 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 justify a waiver of that portion of
the applicable ANSI standard. For an applicant the waiver request must be made on the NRC Form 398, "Personal Qualification Statement - Licensee," by
checking Box 12.c.3 and justifying the waiver/exception request in Box 25.
Box 10 - RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL - Additional condition request, modification of an existing condition or deletion of an
existing condition. Must include an explanation in the Explanation Box and provide Medical Evidence.
Box 11 - INFORMATION ONLY - Check box if providing required established medical status updates that do not request new restrictions, removal of
restrictions or change in status report frequency. Use for reporting any other medical situation you determine that needs to be reported to the NRC. Do not
report medical conditions for operators on administrative hold.
SECTION B - SIGNATURE - Applicant/Operator
SECTION C - CERTIFICATION - Senior Management Representative
Detach these instructions and submit the Original NRC Form 396 with the NRC Form 398 for applicants or with a cover letter for operators who do not
meet minimum requirements during licensure to the appropriate address.
In accordance with 10 CFR 55.5, this form shall be submitted to the appropriate NRC office electronically by the EIE system or by mail to:
REGIONAL ADMINISTRATOR, REGION I
U.S. NUCLEAR REGULATORY COMMISSION
2100 RENAISSANCE BOULEVARD, SUITE 100
KING OF PRUSSIA, PA 19406-2713
REGIONAL ADMINISTRATOR, REGION IV
U.S. NUCLEAR REGULATORY COMMISSION
1600 E. LAMAR BOULEVARD
ARLINGTON, TX 76011-4511
NRC FORM 396 (MM-YYYY)

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