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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: 09-11-2024
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:

Bernard Litkett, Reactor Engineer (Examiner Qualified)

NRR/DRO/IOLB

(301)415-3657 or Bernard.Litkett@nrc.gov

 

Page Last Reviewed/Updated Tuesday, September 17, 2024