10 C.F.R. § 53.765
(b) To certify the medical fitness of an applicant for an operator or senior operator license, an authorized representative of the facility licensee must 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 website at https://www.nrc.gov and selecting forms from the index found on the home page, or by other means provided by the NRC.