10 CFR § 55.23 - Certification.
To certify the medical fitness of the applicant, an authorized representative of the facility licensee shall complete and sign NRC Form 396, “Certification of Medical Examination by Facility Licensee,” which can be obtained by writing the Office of the Chief Information Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555–0001, by calling (301) 415–7232, or by visiting the NRC's Web site at http://www.nrc.gov and selecting forms from the index found on the home page.
(a) Form NRC–396 must certify that a physician has conducted the medical examination of the applicant as required in § 55.21.
(b) When the certification requests a conditional license based on medical evidence, the medical evidence must be submitted on NRC Form 396 to the Commission and the Commission then makes a determination in accordance with § 55.33.