Information Collection

NRC Form 396, Certification of Medical Examination by Facility Licensee

IC 33230 under ICR 200511-3150-002 · OMB 3150-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3150-0024 can be found here:

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Information Collection (IC) Details

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IC Title:	NRC Form 396, Certification of Medical Examination by Facility Licensee	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	396				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 137	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,287	47	1,240
Annual IC Time Burden (Hours)	758	7	751
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.