NRC Form 396, Certification of Medical Examination by Facility Licensee

Documents and Forms

Document Name Document Type
Form NRC Form 396 NRC Form 396, Certification of Medical Examination by Facility Licensee Form and Instruction
NRC Form 396 ONLINE FORM -CERTIFICATION OF MEDICAL EXAMINATION BY FAC New 396 web version updated 8_6 (2)_WITH EDITS 12_8_2025.pdf Form and Instruction
NRC Form 396 FORM 396 -CERTIFICATION OF MEDICAL EXAMINATION BY FACILI NRC 396 (OMB Copy 3) (12-08-2025) KB.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NRC Form 396	ONLINE FORM -CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE	New 396 web version updated 8_6 (2)_WITH EDITS 12_8_2025.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NRC Form 396	FORM 396 -CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE	NRC 396 (OMB Copy 3) (12-08-2025) KB.pdf		Yes	Yes	Fillable Fileable

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: 133	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,862	84	1,778
Annual IC Time Burden (Hours)	2,161	98	2,063
Annual IC Cost Burden (Dollars)	55	7	48

Documents for IC

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