NRC 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)

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

11. Type of Application (Check applicable boxes)

EXPIRES: (MM/DD/YYYY)

Date Received

(To be completed by NRC)

4. Birth Date: (MM/DD/YYYY) 5. E-mail Address (electronic correspondence option)

9. State

8. City

10. Zip Code

12. Deferrals/Excusal/Waivers (See instructions, check all that apply and justify in item 25)

E. REAPPLICATION

A. NEW

Suffix

3. Middle Initial

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 FOIA, Library, and Information Collections Branch (T-6 A10M), U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and the
OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0090), Attn: Desk Officer for the Nuclear
Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The
NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
document requesting or requiring the collection displays a currently valid OMB control number.

b. EXCUSAL

a. DEFERRAL

c. WAIVER

B. RENEWAL

1 - FIRST DENIAL

1 - ELIGIBILITY

1 - WRITTEN

(Category)

1 - WRITTEN

(Category)

C. UPGRADE

2 - SECOND DENIAL

2 - EXPERIENCE

2 - OPERATING

(Category)

2 - OPERATING

(Category)

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

3 - THIRD DENIAL

3 - MEDICAL

4 - WITHDRAWAL

4 - OTHER

13. Type of License Applied for:

OPERATOR (RO)

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

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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
a. Hours Operated at
Facility

< 100 (LESS THAN)
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

NRC FORM 398 (MM-YYYY)

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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

26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED

Yes

No

27. Signatures

ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
27a.

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 and Date - Applicant (Sign in black ink or Digital Signature)

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 and Date - Training Coordinator (Sign in black ink or Digital Signature)

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

Signature and Date - Senior Management Representative on Site (Sign in black ink or Digital Signature)

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

DOES NOT MEET REQUIREMENTS

Signature and Date (Sign in black ink or Digital Signature)

NRC FORM 398 (MM-YYYY)

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NRC FORM 398

(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS)

How to complete this form: You must complete items 1- 4 and 6-10 and additional items as specified below in the
instructions for Block 11, “Type of Application.” For additional guidance refer to NUREG-1021, "Operator
Licensing Examination Standards for Power Reactors," or NUREG-1478, "Non-Power Reactor Operator
Licensing Examiner Standards."
5. E-MAIL ADDRESS If you provide an email address, you are electing to receive operator licensing
correspondence from the NRC, electronically. If you do not provide an email address, the NRC will correspond
using mail to the address you provided in Items 6-10.
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 11-13, 14 (if applicable), and 15-23. 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 11, 14, 18, 20, 21.f and 24; 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 11-18, 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 11-19, and 21-23. Complete item 21 as it applies to unit differences.
E. REAPPLICATION - “X” if you have previously been denied a license. Complete items 11-19, 21-23, 25.
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. If you previously withdrew an application, check
item 11.E.4.
12. EXCUSAL/DEFERRAL/WAIVER - 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. Identify the
specific requirement and indicate the expected completion time for each requirement in item 25.
b. EXCUSAL - “X” if you are requesting to have a previously passed portion of the NRC exam excused. 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 examination excusals, check box 12.b.1 and enter a category of “SSR” for the site-specific RO
examination or “SSS” for the site-specific RO and SRO examinations.
For the operating test, the available categories are: administrative topics, control room systems, in-plant systems,
simulator operating test, JPM operating test or all of these. Check box 12.b.2 and enter a category of “SIM” for
simulator operating test, “JPM” for the complete JPM operating test, "SYS" for the systems portion of the JPM
operating test (i.e., for an “ADMIN-only JPM retake exam), “ADM” for the administrative portion of the JPM
operating test, “OTH” for another JPM combination not listed here (explain in item 25), or “ALL” 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 of the operating test will not be excused. Provide
justification in item 25.
NRC FORM 398 (MM-YYYY)

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(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

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

c. WAIVER - “X” if you are requesting a waiver (55.47). 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 all waivers, provide additional justification information in item 25.
14. DOCKET AND LICENSING INFORMATION - Provide applicable information for the individual that is
applying for the license. Include the individual's docket number if the applicant has previously been assigned a
docket number. Leave blank if applicant has not been assigned a docket number. For power reactors, a docket
number will be provided after the application is received, via NUREG-1021 Form 2.2-1, List of Applicants. If a
license number is provided, then include the associated facility docket number for that license. For facility docket
numbers, check the associated type (050 or 052) and then fill in the last 5 digits of the facility docket number.
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 - (This item is not applicable to non-power
reactors). 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 you requested a deferral in item 12.a, you
can still check “Yes” for item 20.a.
21. TRAINING - (For power reactors, if “Yes” is checked in items 20.a and 20.b, then this item is not required to
be completed.) All re-qualification training time is to be accounted for in item 21.f (unless items 20.a and 20. b
are 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. If needed, use item 25, or attach
a separate document to this form.
23. EXPERIENCE DETAILS - (For power reactors, if “Yes” is checked in items 20.a and 20.b, then this item is
not required to be completed unless applicant is a certified instructor seeking an SRO license.) 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 block 25, or
attach a separate document to this form.
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.
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 include extra information as a separate document
with your application.
26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE, IS
ATTACHED - NRC Form 396 and any applicable supporting medical documentation must accompany this
application unless a waiver of the medical examination is being requested in item 12.c.3.
27. SIGNATURES - You must sign and date item 27.a. Obtain signatures of your training coordinator and the
senior management representative on site.
NRC FORM 398 (MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 398

(MM-YYYY)

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

How to submit this form: This form must be submitted by mail to the appropriate NRC office, at the address
listed below, or by Electronic Information Exchange (EIE), or NRC Box (if a Box has been established to submit
documents to the NRC). EIE is the preferred method. When using EIE: If a field is not applicable, leave the item
block blank. If using a scanner to send the form, a scanner setting of 600 DPI is preferred. Do NOT include the
form instructions when submitting completed NRC Forms 398 and 396. Detailed guidance on electronic
submissions can be obtained by visiting the NRC's web site at http://www.nrc.gov/site-help/e-submittals; by email to MSHD.Resource@nrc.gov; or by writing the Office of the Chief Information Officer, U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001.
ADDRESSES
This form may be submitted by mail and 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

DIRECTOR, DIVISION OF ADVANCED REACTORS AND NON-POWER PRODUCTION AND UTILIZATION
FACILITIES OFFICE OF NUCLEAR REACTOR REGULATION
U.S. NUCLEAR REGULATORY COMMISSION
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 84 FR 71548
(December 27, 2019), 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.