United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > NRC Forms > NRC Form 396 - Certification of Medical Examination by Facility Licensee

NRC Form 396 - Certification of Medical Examination by Facility Licensee

Form Number: NRC Form 396 PDF Icon (With Instruction) | NRC Form 396 PDF Icon (Without Instruction)
Form Title: Certification of Medical Examination by Facility Licensee
Current Edition: 01-2016
Authority Directive or Regulation:

10 CFR 55.21, 55.23, 55.25, 55.27, 55.31, 55.33 and 55.57

Form Status: Approved by OMB: 3150-0024, Expires: 03/31/2016
Special Instructions:

Instructions are on Page 2 of the form.

NRC Form 396, "Certification of Medical Examination by Facility Licensee," must accompany the NRC Form 398 unless a waiver of the medical examination is being requested.

Page Last Reviewed/Updated Thursday, January 07, 2016