Form Online PART 20 RESPIRATOR PROTECTION EXEMPTION REQUEST FOR NON-

Part 20 Respirator Protection Exemption Request for Research and Test Reactors/Non-Power Reactors

By letter dated April 27, 2020 (ADAMS Accession No. ML20099G757), the U.S. Nuclear Regulatory Commission (NRC) provided guidance to the nuclear industry regarding the expedited review of licensee-requested exemptions from the medical examination frequency requirements in 10 CFR 20.1703(c)(5)(iii) and the fit-testing frequency requirements in 10 CFR 20.1703(c)(6) during the COVID-19 Public health Emergency (PHE). As detailed in the April 27, 2020 letter, the NRC will expeditiously review requests from individual licensees for exemptions from these requirements if those requests meet certain elements. This form is intended for use by research and test reactor/non-power reactor licensees to request these exemptions.

If the licensee determines that it cannot meet the expedited review criteria described in the April 27, 2020 letter, or requests one or more exemptions from different Part 20 provisions, then the licensee may seek separate NRC approval through the normal exemption process.

APPROVED BY OMB NO. 3150-0014 Expiration Date: XX/XX/20

Estimated burden per response to comply with this collection request: 2 hours. This form is used to submit COVID-19 related requests for an exemption from certain requirements in 10 CFR Part 20. Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202 (3150-0014), 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.

Demographics

1. Submitter Name/Title

2. Email Address

3. Organization

4. Facility Name

5. Need By Date

6. Enter Docket Number(s)

7. Enter License Number(s)

8. NRC Licensing Project Manager

Medical Evaluation Exemption

9. For a medical evaluation frequency exemption under 10 CFR 20.1703(c)(5)(iii), check the YES box and answer questions 10-17. If you are not filing for a medical evaluation frequency exemption, check the NO box and proceed to question 18.

• YES

• NO

Medical Evaluations: To receive expedited review of a request for exemption from 10 CFR 20.1703(c)(5)(iii), provide the information stated in questions 10-17 below:

10. A statement indicating whether the licensee cannot meet the medical evaluation requirements of 10 CFR 20.1703(c)(5)(iii) without workers taking actions that may be contrary to CDC’s guidance for responding to the COVID-19 PHE:

11. A statement indicating whether the licensee will, for the duration of any exemption approved by NRC, apply a licensee-specific process to manage personnel with overdue medical evaluations while ensuring the safety of workers:

12. An estimate of the number of personnel who would be covered by the exemption and their organizational positions, using generic position descriptions, that would be included in the licensee-specific process (e.g., position/number of people):

13. The date and time when the exemption would be implemented, if approved, and when the licensee-specific process would take effect:

14. A statement indicating whether this exemption would only be used by personnel having known, stable medical histories as determined and documented by a licensed physician:

15. A statement indicating whether, except for physical medical examinations at medical facilities, the licensee has completed, or will complete within the required frequency (plus a 90-day grace period), all applicable respiratory protection program medical evaluation requirements (e.g., medical history questionnaire):

16. A statement indicating whether a licensed physician has reviewed the medical history questionnaire prior to the expiration of the current medical evaluation (plus a 90-day grace period) and has determined and documented that an extension of the wearer’s physical medical evaluation due date is acceptable such that the wearer remains qualified to use assigned respiratory protection equipment during the extension:

17. Additional Information

Use the area below to provide any additional information related to your exemption request:

Note: The NRC may condition the exemption with the following conditions.

• The exemption does not apply, and the existing regulations continue in effect when:

• an employee reports signs or symptoms that could affect his or her ability to use a respirator (unless cleared by a licensed physician);

• a physician or other licensed health care professional, supervisor, or respirator program administrator informs the licensee that an employee needs to be reevaluated;

• information from the respiratory protection program, including observations made during fit-testing and program evaluation, indicates a need for employee reevaluation; or

• a change occurs in workplace conditions (e.g., physical work effort, protective clothing, temperature) that may result in a substantial increase in the physiological burden placed on an employee.

• All employees affected by this exemption must be informed of the general risks of wearing respiratory protection (e.g., information similar to that found in Appendix D of 1910.134), the rationale for medical evaluations (e.g., information similar to that found in American National Standards Institute (ANSI) Z88.6-2006), the contents of this exemption, and the requirement that the licensees will return to compliance within 90 days of the end of the PHE or December 31, 2020, whichever is sooner.

Fit-Testing Exemption

18. For a fit-testing frequency exemption under 10 CFR 20.1703(c)(6), check the YES box and answer questions 19-23. If you are not filing for a fit-testing frequency exemption, check the NO box and click Submit.

• YES

• NO

Fit-Testing Requirements: To receive expedited review of a request for exemption from 10 CFR 20.1703(c)(6), provide the information stated in questions 19-23 below:

19. A statement indicating whether the licensee cannot meet the fit-testing requirements of 10 CFR 20.1703(c)(6) without workers taking actions that may be contrary to CDC guidance for responding to the COVID-19 PHE:

20. A statement indicating whether the licensee will, for the duration of any exemption approved by the NRC, apply a licensee-specific process to manage personnel with overdue respiratory protection fit-tests, while ensuring the safety of workers:

21. An estimate of the number of personnel who will be covered by the exemption and their organizational positions, using generic position descriptions, that will be included in the licensee-specific process (e.g., position/number of people):

22. The date and time when the exemption would be implemented, if approved, and when the licensee-specific process would take effect:

23. Additional Information

Use the area below to provide any additional information related to your exemption request:

Note: The NRC may condition the exemption with the following conditions.

• The exemption applies only to personnel who had a fit-test within the past year (plus a 90-day grace period).

• Affected wearers will be assigned only respirators that match the make, model, and size of the respirator facepiece with which they last performed their fit-test.

• The exemption does not apply when an individual has experienced the following situations:

• An obvious change in body weight;

• Significant facial injury or scarring in the area of the tight-fitting respirator facepiece seal;

• Significant dental changes (e.g., multiple extractions without prosthesis or acquisition of new dentures);

• Reconstructive or cosmetic surgery in the area of the tight-fitting; respirator facepiece seal; or

• Any other condition that might change the fit of the tight-fitting respirator.

• All employees affected by this exemption will receive refresher training on donning their assigned respirator and will be informed of the rationale for respiratory fit-testing (e.g., information similar to that found in American National Standards Institute (ANSI Z88.10-2001), the contents of this exemption, and the requirement that the licensees will return to compliance within 90 days of the end of the PHE or December 31, 2020, whichever is sooner.