Form 396 2026

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4.2 out of 5

96 votes

The document is NRC Form 396, which certifies the medical examination of applicants/operators for nuclear facility licenses. It outlines the requirements for assessing the physical and mental health of operators to ensure they can perform their duties safely. The form includes sections for personal information, medical exam results, physician's certification, and potential restrictions based on medical conditions. It emphasizes compliance with NRC regulations and provides instructions for submission.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the applicant's last name, first name, and middle initial in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the applicant/operator docket number and facility details. This includes the facility name and its corresponding docket number, which can be separated by a semicolon if there are multiple.
In Section A, provide medical exam information including the physician's printed name, certification date, license number, and state of licensure. Make sure to check the appropriate guidance document used for assessment.
Review and select any necessary restrictions based on the physician’s recommendations. For each selected restriction, provide explanations in the designated box below.
Complete Sections B and C by signing where indicated. The applicant/operator must sign in black ink, followed by a senior management representative's signature certifying the information provided.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (133 Votes)
2019	4.2 Satisfied (96 Votes)

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