Information Collection

NRC Form 396, Certification of Medical Examination by Facility Licensee

IC 33230 under ICR 202205-3150-006 · OMB 3150-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0024 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NRC Form 396 NRC Form 396, Certification of Medical Examination by Facility Licensee	Form and Instruction
NRC Form 396 NRC Form 396, Certification of Medical Examination by Fa NRC 396 (Draft 1) (12-27-2021) (2).pdf	Form and Instruction
NRC Form 396 NRC Form 396, Certification of Medical Examination by Fa NRC 396 (Draft 1) (12-27-2021) (2).pdf	Form and Instruction

IC Title:

NRC Form 396, Certification of Medical Examination by Facility Licensee

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 55

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 396	NRC Form 396, Certification of Medical Examination by Facility Licensee	NRC 396 (Draft 1) (12-27-2021) (2).pdf		Yes	Yes	Fillable Printable

Line of Business: Energy

Subfunction: Energy Resource Management

Privacy Act System of Records

Title: NRC 16: Facility Operator Licensee Records

FR Citation: 84 FR 71536

Number of Respondents: 128

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,778	21	1,757
Annual IC Time Burden (Hours)	2,063	-133	2,196
Annual IC Cost Burden (Dollars)	48	48	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.