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NRC Form 396 – Certification of Medical Examination by Facility Licensee

Form Number: NRC Form 396 PDF Icon
Form Title: Certification of Medical Examination by Facility Licensee
Current Edition: 10-2019
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:

Skylar Cushing, Reactor Engineer (Examiner Qualified), NRR/DIRS/IOLB
(301) 415-1064 or Skylar.Cushing@nrc.gov

Page Last Reviewed/Updated Wednesday, September 16, 2020