NRC Form 396 – Certification of Medical Examination by Facility Licensee

Form Number:	NRC Form 396
Form Title:	Certification of Medical Examination by Facility Licensee
Current Edition:	01-03-2023
Authority Directive or Regulation:	10 CFR 55.21, 55.23, 55.25, 55.27, 55.31, 55.33, 55.53 and 55.57
Form Status:	Approved by OMB: 3150-0024, Expires: 12-31-2025 Changes to this revision of the form include addition of date of birth and email address, correction of editorial errors, and updated NRC addresses.
Special Instructions:	Instructions are provided with 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. For questions, please call or e-mail: Skylar Cushing, Reactor Engineer (Examiner Qualified) NRR/DRO/IOLB (301)415-1064 or Skylar.Cushing@nrc.gov

Page Last Reviewed/Updated Tuesday, January 17, 2023