Form 398 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, 55.33,
55.35, 55.47, 55.53,
and 55.57.

PERSONAL
QUALIFICATION
STATEMENT -- LICENSEE

1. Last Name

2. First Name

6. Address (Number & Street, line 1)

Suffix

3. Middle Initial

7. Address (Suite, Unit No, etc., line 2)

11. Type of Application (Check applicable boxes)

9. State

10. Zip Code

12. GFE and Deferrals/Excusals/Waivers (See instructions, check all that apply and justify in item 25)
b. EXCUSAL

a. DEFERRAL

B. RENEWAL

1 - FIRST DENIAL

C. UPGRADE

2 - SECOND DENIAL

D. MULTI-UNIT (amend
to include additional unit)

3 - THIRD DENIAL

c. WAIVER

1 - ELIGIBILITY

1 - WRITTEN

(Category)

1 - WRITTEN

(Category)

2 - EXPERIENCE

2 - OPERATING

(Category)

2 - OPERATING

(Category)

d. DATE PASSED GFE

4 - WITHDRAWAL

13. Type of License Applied for:

DATE RECEIVED
(To be completed by NRC)

4. Birth Date: (MM/DD/YYYY) 5. E-mail Address (See box 27a. Electronic correspondence option)

8. City

E. REAPPLICATION

A. NEW

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0090

Estimated burden per response to comply with this mandatory collection request: 2.56 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 Information Services Branch
(O1-F21), 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.

(MM)

Select

OPERATOR (RO)

3 - MEDICAL
4 - OTHER

(YY)

LIMITED (LSRO)

SENIOR OPERATOR (SRO)

14. Docket and Licensing Information
Docket Number

RO

055 -

Facility Docket Number (Separate multiple docket numbers by ";")

License Number(s)

Expiration Date(s)

16. Facility Docket Number

17. Additional Facility Docket Number(s) (Multi-unit Licenses)

050

LSRO

052

SRO
15. Name of Applicant's Facility

050
052

18. Current Position at Facility
A. Plant Supervisor/Manager

E. Shift Technical Advisor/Shift Engineer

I. Trainee

B. Assistant Plant Superintendent/Manager

F. Instructor

J. Non-Licensed Operator

C. Shift Supervisor

G. Senior Control Room Operator

K. Other

D. Staff Engineer

H. Control Room Operator
19. Education

a. High School

b. College

Graduate

Major Area(s) of Study

Number
of Years

HIGHEST DEGREE
(Use Codes)

c. Vocational/Technical

DEGREE CODES
("Highest Degree" obtained)
0 - None
1 - Certificate
2 - Associate
3 - Bachelor
4 - Master
5 - Doctoral

Type of Training

Number of
Months

Certificate Received
Yes

No

Yes

No

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?

Yes

No

GED Equivalency Engineering
No

Other:

20. Power Reactor Operator Training Program

21. Training (Since Last Application - See Instructions)
a. Classroom

From (MM/YYYY) To (MM/YYYY) No. of Weeks

From (MM/YYYY) To (MM/YYYY) No. of Weeks

1 - Nuclear Power Plant Fundamentals

d. Extra Person on Shift in Control Room

2 - Plant Systems

e. Time on Shift Above 20% Power

3 - Plant Procedures

f. Requalification

b. Simulator

g. Other (Specify below)

c. SRO Instruction
22. Significant Control Manipulations
DESCRIPTION

PLANT SIMULATOR

DESCRIPTION

a.

f.

b.

g.

c.

h.

d.

i.

e.

j.

NRC FORM 398 (MM-YYYY)

PLANT SIMULATOR

Page 1 of 3

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 398

(MM-YYYY)
10 CFR 55.31, 55.33,
55.35, 55.47, 55.53,
and 55.57.

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

1. Last Name

2. First Name

3. Middle Initial

Suffix

Docket Number

055 23. Nuclear Experience Details
POSITION TITLE

FROM DATE
(MM/YYYY)

TO DATE
(MM/YYYY)

MONTHS

FACILITY

DUTIES

24. For Renewals Only
< 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.

MM/YYYY

Result

W

PASS

FAIL

O

PASS

FAIL

25. Comments

26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED
NRC FORM 398 (MM-YYYY)

Yes

No
Page 2 of 3

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 398

(MM-YYYY)
10 CFR 55.31, 55.33,
55.35, 55.47, 55.53,
and 55.57.

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

1. Last Name

2. First Name

3. Middle Initial

Suffix

055 -

Docket Number

27. Signatures

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 correct in accordance with the instructions. I also authorize
the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
Signature - Applicant (Sign In Black Ink)
Date

27a.

Electronic Correspondence Option: By checking this box, you are acknowledging that the NRC will be providing operator licensing correspondence electronically.
27b. CHECK APPLICABLE BOX(ES) FOR TYPE OF APPLICATION (i.e., check 1 if item 11 a, c, d, or e is checked; check 2 if item 11 b is checked; and check 3 if item
12 a, b, or c is checked.)
1. 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
Title10, 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.
2. I certify that the above named individual completed the approved requalification program (with the exceptions noted in Item 25) 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.
3. I certify that the justifications provided in item 25 support the deferrals, excusals, and/or waivers requested in item 12 for the above named individual. I also certify
under penalty of perjury that the information in this document and attachments is true and correct in accordance with the instructions.
Training Coordinator
Typed or Printed Name and Title (Training Coordinator)

Signature (Training Coordinator) (Sign In Black Ink)

Date

Senior Management Representative on Site
Typed or Printed Name and Title (Senior Management Representative on Site)

Signature (Senior Management Representative on Site) (Sign In Black Ink)

Date

FOR NRC USE
Deferral/Excusal/Waiver Requests
(Check or Complete items, as applicable)

Deferral

Excusal

GRANTED BY

HEADQUARTERS

DENIED BY

REGION

HEADQUARTERS

REGION

Eligibility
Experience
Written
Operating
Written
Operating

Waiver

Medical
Other

Explanation:

MEETS REQUIREMENTS
Signature (Sign In Black Ink)

NRC FORM 398 (MM-YYYY)

DOES NOT MEET REQUIREMENTS
Date

Page 3 of 3

NRC FORM 398
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)

You must complete items 1-11, 13-18, 20, 25-27, 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."
11. TYPE OF APPLICATION
A. NEW - “X” if you are a new applicant at this facility (i.e., this is your first request to take the site-specific NRC exam at this facility). Complete items 12.d,
13, 18-23 (10 CFR 55.31). If 20.a and 20.b are checked "Yes" then item 21 does not have to be completed.
B. RENEWAL - “X” if you are renewing a current license. Complete items 20, 21.f and 24 (10 CFR 55.57); if items 20.a and 20.b are checked “Yes” then
item 21.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, 21 and 23
relevant to the SRO upgrade. If items 20.a and 20.b are checked "Yes" then item 21 does not have to be completed.
D. MULTI-UNIT - “X” if you hold a license at your facility and are applying to amend your current license to an additional unit. Complete items 12, 19, and
21-23. Complete item 21 as it applies to unit differences.
E. REAPPLICATION - “X” if you have previously been denied a license. Indicate whether you are applying after a first denial, second denial, or third
denial. Describe, in detail, in items 21 and 25, the additional training completed since the last denial (10 CFR 55.35). Complete items 12, 19, 22-23. If you
previously withdrew an application, check item 11.E.4.
12. GFE and Excusals/Deferrals/Waivers - Refer to NUREG-1021 or NUREG-1478 for additional guidance.
a. Deferral - “X” if you are requesting a deferral of certain requirements to be able to sit for the scheduled NRC exam. Check which requirements (1 Eligibility or 2 - Experience) you are requesting deferral of. Indicate the expected completion time for these requirements in item 25.
b. Excusal - “X” if you are requesting to have a previously passed portion of the NRC exam excused (10 CFR 55.35(b)). Indicate which requirements of
the requested portion you are requesting excusal from (1 - Written or 2 - Operating), and indicate the category.
For Power Reactors:
For written exam excusals, check box 12.b.1 and enter a category of “SSR” for the site-specific RO exam or “SSS” for the site-specific RO and SRO exams.
For operating test excusals, check box 12.b.2 and enter a category of “SIM” for simulator operating test ONLY, “JPM” for the complete JPM operating test
ONLY, "SYS" for the systems portion of the JPM operating test ONLY (i.e., for an “Admin-only” JPM retake exam), or OPT to request excusal from both the
simulator operating test and the complete JPM operating test. Provide justification in item 25. Also indicate the expected date of the NRC exam.
For Non-Power Reactors:
For written exam excusals, check box 12.b.1 and enter a category of “A": to request an excusal of category A, enter a category of “B” to request an excusal
of category B, enter a category of “C” to request an excusal of category C. For operating test excusals, check box 12.b.2 and enter a category of “ALL” to
request excusal of an operating test. Individual categories will not be excused.
c. Waiver - “X” if you are requesting a waiver. For waivers of the written examination and/or operating test, check 12.c.1 and/or 12.c.2 respectively and
identify the examination categories using the same designations identified in the instructions for 12.b above. For medical waivers, check 12.c.3. For GFE
waivers, check 12.c.4. For all waivers, provide additional justification information in item 25.
d. Date passed GFE - This is not applicable to research and test reactors, licenses limited to fuel handling (LSRO), renewal or upgrade applications
(items 11.b and 11.c). Enter month and year you passed GFE for the type of facility (BWR/PWR) identified in item 15. If this date is more than two years
prior to the date of your application, item 12.c.4 must be checked, and the method used to justify the GFE waiver must be described in item 25.
19. 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 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 25.
20. POWER REACTOR OPERATOR TRAINING PROGRAM - Check the appropriate box in items 20.a and 20.b.
Checking “Yes” in item 20.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 in 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 20.a and 20.b, then items 21 and 23 do not have to be completed with the following
exceptions: (1) certified instructors seeking an SRO license must complete item 23; (2) any exceptions, deferrals, or waivers from the education and
experience requirements outlined by the National Academy for Nuclear Training must be explained in item 25.
21. TRAINING - All re-qualification training time is to be accounted for in item 21.f (unless items 20.a and 20. b are checked “Yes”). Do not “double list” the
time spent in re-qualification training for classroom or simulator time under items 21.a or 21.b.
22. SIGNIFICANT CONTROL MANIPULATIONS - If you are a NEW applicant (item 11.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 item 25 or attach information.
23. 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 25 or attach additional information.
NRC FORM 398 (MM-YYYY)

NRC FORM 398
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)(continued)

24. 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).
25. 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.
26. 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 12.c.3 (10 CFR 55.23).
27. SIGNATURES - You must sign and date item 27a. If you prefer to check the Electronic Correspondence Option, you will be authorizing the NRC to
forego receiving paper documents and receiving your operator license related correspondence using the Electronic Information Exchange. The NRC will
automatically create a digital certificate for you to allow you to access your documents from a secure location for quicker access to your documents. If you
do not check this box, the NRC will provide your correspondence using ground mail. Obtain signatures of your training coordinator and the senior
management representative on site.
ADDRESSES
In accordance with 10 CFR 55.5, Communications, this form shall be submitted by mail to the appropriate NRC office. Where practicable, submission shall
be electronic; examples include via Electronic Information Exchange or CD-ROM. Electronic submissions must be made in a manner that enables the NRC
to receive, read, authenticate, distribute, and archive the submission, and process and retrieve it a single page at a time. Detailed guidance on making
electronic submissions can be obtained by visiting the NRC's Web site at http://www.nrc.gov/site-help/e-submittals.html; by e-mail to
[email protected]; or by writing the Office of the Chief Information Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555 -0001.
This form may also be submitted 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 III
U.S. NUCLEAR REGULATORY COMMISSION
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352

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

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
OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, DC 20555-0001

PRIVACY ACT STATEMENT
NRC FORM 398
PERSONAL QUALIFICATION STATEMENT -- LICENSEE
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 81 FR 81331 (November 17, 2016), 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. 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.
NRC FORM 398 (MM-YYYY)