Form NRC Form 396 NRC Form 396 ONLINE FORM -CERTIFICATION OF MEDICAL EXAMINATION BY FAC

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PERSONALLY IDENTIFIABLE INFORMATION -WITHHOLD UNDER
10 CFR 2.390
Form 396 - CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY
LICENSEE.

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Estimated burdefl per response 10 comply wtth this voluntary collection request: 1 hour. NRC requires this informatioo 10 determine that the physical condttion and heaMh of operator
licensees is such that the applicant woulcl not be expected to cause operational errors endangering the public health and safety Send comments regarding burden estimate to the
FOIA, library. and lnformalioo Col~ions Branch (T-QA10M). U.S. Nuclear Regulatory Commission , Washington . DC 20555--0001 , and the 0MB reviewef at: 0MB Office of
lnfomlation aflCI Regulatory Affaifs, {3150-0024). Attn : Desk Officer lor trte Nuclear Regulatory Commission. 725 17th Street NW. Washington, DC 20503. Tile NRC may not conauct or
sponsor, and a person is not requireut can
demonstrate complete capacity to perform assigned duties, as proven by a test adminiStered by the physieian, the physieian may recommend and justify a waiver or that
portion or the applicable ANSI standard. For an applicant the waiver request must be made on the NRC Form 398, "Personal Oualifieation Statement - Licensee," by
Checking Box 12.c.3 and justifying the waiver/exception request in Box 25.

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10. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL

Additional license condition request , modiflCatiOn or an existing conditiOn or deletion or an existing conditioo. Must include an explanation in the Explanation Box and
provide Medical Evidence.

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11. Information Only

Check box if providing required established medical status updates that do not request new restrictions , removal of restrietiOns or change in status report frequency.
Use for reporting any other medical situalion you determine that needs to be reporteFile Typeapplication/pdfFile TitleMicrosoft Word - New 396 web version updated 8_6.docxAuthorLAH1File Modified2025-12-08File Created2025-08-06