NRC Form 396 – Certification of Medical Examination by Facility Licensee

NRC Form 396

Certification of Medical Examination by Facility Licensee

01-01-2026

10 CFR 55.21, 55.23, 55.25, 55.27, 55.31, 55.33, 55.53 and 55.57

Approved by OMB: 3150-0024, Expires: 01/31/2026
Changes to this revision of the form include addition of date of birth and email address, correction of editorial errors, and updated NRC addresses.

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