Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

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: Rebecca Riggs, Reactor Engineer (Examiner Qualified) NRR/DRO/IOLB (423) 855-6512 or Rebecca.Riggs@nrc.gov

Page Last Reviewed/Updated Wednesday, July 30, 2025