6. Address (Number & Street, line 1)

1. Last Name

PERSONALLY IDENTIFIABLE INFORMATION - WITHHOLD UNDER 10 CFR 2.390

NRC FORM 398

(07-05-2023)

10 CFR 55.31, 55.33, 

55.35, 55.47, 55.53, 

and 55.57.

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION 

STATEMENT -- LICENSEE

APPROVED BY OMB: NO. 3150-0090 EXPIRES: 01/31/2026 

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 email 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; email: 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.

DATE RECEIVED 

(To be completed by NRC)

2. First Name 3. Middle Initial 4. Birth Date: (MM/DD/YYYY) 5. Email Address (Electronic correspondence option)

7. Address (Suite, Unit No, etc., line 2) 8. City 10. Zip Code

11. Type of Application (Check applicable boxes)

A. NEW

B. RENEWAL

C. UPGRADE

D. MULTI-UNIT (amend 

to include additional unit)

E. REAPPLICATION

1 - FIRST DENIAL

2 - SECOND DENIAL

3 - THIRD DENIAL

4 - WITHDRAWAL

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

a. DEFERRAL

1 - ELIGIBILITY

2 - EXPERIENCE

b. EXCUSAL

1 - WRITTEN (Category)

2 - OPERATING (Category)

c. WAIVER

1 - WRITTEN (Category)

2 - OPERATING (Category)

3 - MEDICAL

4 - OTHER

13. Type of License Applied for: OPERATOR (RO) SENIOR OPERATOR (SRO) LIMITED (LSRO)

14. Docket and Licensing Information

055 -

Docket Number RO

LSRO

SRO

License Number(s) Expiration Date(s)

050

052

050

052

18. Current Position at Facility

A. Plant Supervisor/Manager

B. Assistant Plant Superintendent/Manager

C. Shift Supervisor

D. Staff Engineer

E. Shift Technical Advisor/Shift Engineer

F. Instructor

G. Senior Control Room Operator

H. Control Room Operator

 I. Trainee

 J. Non-Licensed Operator

 K. Other 

19. Education

a. High School

Graduate

GED Equivalency

No

b. College

Major Area(s) of Study Number 

of Years

HIGHEST DEGREE 

(Use Codes)

Engineering

Other:

DEGREE CODES 

("Highest Degree" obtained) 

 0 - None 

 1 - Certificate 

 2 - Associate 

 3 - Bachelor 

 4 - Master 

 5 - Doctoral

c. Vocational/Technical

Type of Training

 Number of 

Months Certificate Received

Yes No

Yes No

20. Power Reactor Operator Training Program

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

21. Training (Since Last Application - See Instructions)

a. Classroom From (MM/YYYY) To (MM/YYYY) No. of Weeks

1 - Nuclear Power Plant Fundamentals

2 - Plant Systems

3 - Plant Procedures

b. Simulator

c. SRO Instruction

From (MM/YYYY) To (MM/YYYY) No. of Weeks

d. Extra Person on Shift in Control Room

e. Time on Shift Above 20% Power

f. Requalification

g. Other (Specify below)

22. Significant Control Manipulations

DESCRIPTION PLANT SIMULATOR

a.

b.

c.

d.

e.

DESCRIPTION PLANT SIMULATOR

f.

g.

h.

i.

j.

NRC FORM 398 (07-05-2023) Page 1 of 3

9. State

Suffix

Facility Docket Number (Separate multiple docket numbers by ";")

 15. Name of Applicant's Facility 16. Facility Docket Number 17. Additional Facility Docket Number(s) (Multi-unit Licenses)
NRC FORM 398

(07-05-2023)

10 CFR 55.31, 55.33, 

55.35, 55.47, 55.53, 

and 55.57. PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

U.S. NUCLEAR REGULATORY COMMISSION

1. Last Name 2. First Name 3. Middle Initial

055 -

Docket Number

POSITION TITLE 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 (07-05-2023) Page 2 of 3

FROM DATE 

(MM/YYYY)

TO DATE 

(MM/YYYY)

Suffix

23. Nuclear Experience Details
NRC FORM 398

(07-05-2023)

10 CFR 55.31, 55.33, 

55.35, 55.47, 55.53, 

and 55.57.

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (Continued)

1. Last Name 2. First Name 3. Middle Initial

055 -

Docket Number

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.

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)

Senior Management Representative on Site

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

FOR NRC USE

Deferral/Excusal/Waiver Requests 

 (Check or Complete items, as applicable)

GRANTED BY

HEADQUARTERS REGION

Deferral

Eligibility

Experience

Excusal

Written

Operating

Waiver

Written

Operating

Medical

Other

DENIED BY

HEADQUARTERS REGION

Explanation:

 MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS

NRC FORM 398 (07-05-2023) Page 3 of 3

Suffix

Signature - Applicant Date

Signature - Training Coordinator Date

Signature - Senior Management Representative on Site Date

Signature Date

 26. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY A FACILITY LICENSEE, IS ATTACHED Yes No
NRC FORM 398

(07-05-2023)

U.S. NUCLEAR REGULATORY COMMISSION

PERSONAL QUALIFICATION STATEMENT -- LICENSEE (INSTRUCTIONS) 

NRC FORM 398 (07-05-2023)

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."

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.

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.

5. EMAIL 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, 13, 14, 18, 20, 21.f and 24; if items 

20.a and 20.b are checked “Yes”, then item 21 does not have to be completed.

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

(07-05-2023)

U.S. NUCLEAR REGULATORY COMMISSION

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

NRC FORM 398 (07-05-2023)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

(07-05-2023)

U.S. NUCLEAR REGULATORY COMMISSION

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.

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 87 FR 64270 

(October 24, 2022), 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 Human Factors Branch, Division of Reactor 

Oversight, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

REGIONAL ADMINISTRATOR, REGION I 

U.S. NUCLEAR REGULATORY COMMISSION 

475 ALLENDALE ROAD, SUITE 102 

KING OF PRUSSIA, PA 19406-1415

REGIONAL ADMINISTRATOR, REGION II 

U.S. NUCLEAR REGULATORY COMMISSION 

245 PEACHTREE CENTER AVENUE, NE., SUITE 1200 

ATLANTA, GA 30303-1257

REGIONAL ADMINISTRATOR, REGION III 

U.S. NUCLEAR REGULATORY COMMISSION 

2443 WARRENVILLE ROAD, SUITE 210 

LISLE, IL 60532-4352

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

ADDRESSES 

This form may be submitted by mail and addressed to:

NRC FORM 398 (07-05-2023)