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: 06-2022
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: 09/30/2022
Special Instructions:

Instructions are on Page 1 and Page 3 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. 

For questions, please call or e-mail:

Bernard Litkett, Reactor Engineer (Examiner Qualified),
NRR/DRO/IOLB
(301) 415-3657 or Bernard.Litkett@nrc.gov

Page Last Reviewed/Updated Friday, June 03, 2022