ML100620790

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Fitness for Duty Program Performance Data Report for 2009
ML100620790
Person / Time
Site: Nine Mile Point  Constellation icon.png
Issue date: 02/24/2010
From: Verno A
Constellation Energy Group
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
Download: ML100620790 (24)
v • d • e


Text

P.O. Box 63 Lycoming, New York 13093 CENG a joint venture of A&Constellation C

Enemi bg-eDF NINE MILE POINT NUCLEAR STATION February 24, 2010 U.S. Nuclear Regulatory Commission Washington, DC 20555-0001 ATTENTION:

SUBJECT:

Document Control Desk Nine Mile Point Nuclear Station Unit Nos. 1 & 2; Docket Nos. 50-220 and 50-4 10 Fitness for Duty Propram Performance Data Renort for 2009 In accordance with the requirements set forth in 10 CFR 26.717(e), 10 CFR 26.203 (e)(1) and 10 CFR 26.203 (e)(2), Nine Mile Point Nuclear Station, LLC has compiled and is submitting the enclosed annual Fitness for Duty Program Performance Data Report covering the period January 1, 2009 through December 31, 2009.

Should you have any questions regarding the information in this submittal, please contact Terry Syrell, Director Licensing at (315) 349-5219.

Very truly yours, Anthony Verno Director Security AV/RJC

Enclosure:

NRC FFD Program Performance Data Reporting System cc:

NRC Regional Administrator, Region I NRC Project Manager NRC Senior Resident Inspector CA T

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ENCLOSURE NRC FFD PROGRAM PERFORMANCE DATA REPORTING SYSTEM Nine Mile Point Nuclear Station, LLC February 24, 2010

NRC FFD Program Performance Data Reporting System I Orn.eHee I

Annual Reporting Form forDrug and Alcohol Tests

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NRC FFD Program Performance Data Reporting System 10 CFR Part 26, Subpart I - Managing Fatigue Annual Fatigue Reporting Form SummaoyofWoiverssuonce-26.203(e)(1)(i-ii)

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~ne Help Note1

1) All fields are required except those marked 'optionalP Optional Reference
2) Entries In some form fields may result In Information Optional ReferenceNumberforLicenseeUse SingleForm20091RA being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5) l~andom Employment Type - 26.717(b)(3)

ContractorNendor I

Labor Category - 26.717(b)(3)

Maintenance (Craft)_

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?iFo Test Results - 26.717(b)(4)

Test Validity Not Applicable Test Type(s) for Result(s) Reported Alcohol Testing

Alcohol Only I

19reath Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable) jAlcohol 1 Please Select 71 Date of Collection (mm/dd/yyyy) 0/I2009 Additional Substance (as applicable)

IPlease Select Use NRC Cutoff (Yes / No)lI*

Use NRC Cutoff (Yes / No) l l

Use NRC Cutoff (Yes / No)[e Is this a 24-Hour Reportable Event (Yes /1No)?- 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0]

11 Refusal to Cooperate 11 Other E0 Management Actions - 26.717(b)(8)

Disciplinary Action I1-Year DenialJ Reason(s) for the Action (select all that apply):

[I MRO Confirmation First drug or alcohol positive 0 Resignation/Withdrawal El Subversion

[0 Subsequent positive test result from testing El Misuse 0 Violation of 5-hour abstinence rule

[] Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document Fý4ý ve to Loýýai--PC Port to NkC Print this Report]

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NKIL; i-i-u rogram rertormance Data Keporting bystem Single Positive Test Form Online

ýHlp Optional Reference Number for Licensee Use ISingle Form 2009 2 JL FU Sub Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Followup Employment Type - 26.7 17(b)(3)

Contractor/Vendlor I

Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)? NoN

1) All fields are required except those marked 'optional"
2) Entries in some form fields may result in information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mmlddlyyyy)

Drug Testing jUrine1 Additional Substance (as applicable) 1Please Select I

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported jDrug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

IMarijuana PleaneselectI Use NRC Cutoff (Yes / No)

I Use NRC Cutoff (Yes / No)

(

Use NRC Cutoff (Yes / No)Yes 1

Is this a 24-Hour Reportable Event (Yes /1No)? - 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Please elaborate on the choicels) selected:

0 0

First sample was out of acceptable temoeralture ranue. Seound sarmole was conllected For Refusal to Cooperate 0

Other 03 Cause, under direct observation and was positive.

Management Actions - 26.717(b)(8)

Disciplinary Action Permanent Denial Reason(s) for the Action (select all that apply):

MRO Confirmation

[3 First drug or alcohol positive 0

Resignation/Withdrawal 0

Subversion 0 Second drug or alcohol positive

[3 Subsequent positive test result from testing

[3 Misuse 0

Violation of 5-hour abstinence rele 0

Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting *Clear Signature".

Click to Digitally Sign This. Document SIing Poo TjetSeFnrd Resiport to.N C single Positie Ted 50,0 vamio 1.1.26

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R0 NRC FFD Program Performance Data Reporting System Single Positive Test Form Online Help Optional Reference Number for Licensee Use ISingle Form 2009 3 ST 3rd D Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access I

Employment Type - 26.717(b)(3) aContraorNendor Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity IValid Test Type(s) for Result(s) Reported 1Drug Only Was this collection observed (Yes/No)?- 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

Ilariuana

'eae Select

1) All fields are required except those marked 'optionaP
2) Entries In some form fields may result in Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yyyy) 03022009Z Drug Testing jurine Additional Substance (as applicable) lPlease Select Use NRC Cutoff (Yes / No)*

Use NRC Cutoff (Yes / No)*

Use NRC Cutoff (Yes / No)e Is this a 24-Hour Reportable Event (Yes/ No)?- 26.719(b) No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 11 El Refusal to Cooperate 11 Other 01 Management Actions - 26.717(b)(8)

Disciplinary Action iPermanent Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation 0

First drug or alcohol positive 0 Resignation/Withdrewal o

Subversion El Second drug or alcohol positive 0

Subsequent positive test result from testing O Misuse

[I Violation of 5-hour abstinence rule

§ Other: Please elaborate

[I Sale, Use or Possession in PA I

3r oiie rgts This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

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0-NRC FFD Program Performance Data Single Positive Test Forr Optional Reference Number for Licensee Use ISingle Form 20094CM Ref Select Facility Nine Mile Point Reason for Testing - 260717(b)(5)

Pre-Access l

Employment Type - 26.717(b)(3) contractorNendor I

Labor Category - 26.717(b)(3)

IMaintenance (Craft)

I Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test ValidityI1 Test Type(s) for Result(s) Reported Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

II I

I Reporting System inOlneHl Note

1) Alu fields are required except those marked 'optional'.
2) Entries in some form fields may result In information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yyyy) j/0/2009 Additional Substance (as applicable) 1 Use NRC Cutoff (Yes / No)IZ]

Use NRC Cutoff (Yes / No)IZ]

Use NRC Cutoff (Yes I No)-

Is this a 24-Hour Reportable Event (Yes /1No)? - 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Please elaborate on the choice(s) selected:

0 1First Samole out of acceptable temoerature ranso. reouested another under direct Refusal to Cooperate

[]

Other 03 observation and the donor refused.

Management Actions - 26.717(b)(8)

Disciplinary Action Permanent Denials Reason(s) for the Action (select all that apply):

0 MRO Confirmation E] First drug or alcohol positive 0

Resignation[Withdrawal I& Subversion 0

Second drug or alcohol positive

[0 Subsequent positive test result from testing El Misuse 0

Violation of 5-hour abstinence rule

[] Other:

El Sale, Use or Possession in PA "

This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the.

signature box and selecting "Clear Signature".

Click to Digitally Sign Thit Document Save tP Senod ReportttorNRCtoi 11.2

NRC FFD Program Performance Data Reporting System Single Positive Test Form O'-,nline Help Optional Reference Number for Licensee Use ISingle Form 2009 5 KS Ref Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Er-Access

]

Employment Type - 26.717(b)(3)

Contractor/Vendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)? FYe77 Test Results - 26.717(b)(4)

Test ValidityF1 Test Type(s) for Result(s) Reported Il Was this collection observed (Yes /No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

1) All fields are required except those marked 'optional'.
2) Entries In some form fields may result in Information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mmlddlyyyy) 03042009 Additional Substance (as applicable)

Use NRC Cutoff (Yes / No)[j Use NRC Cutoff (Yes / No)

IZ Use NRC Cutoff (Yes I No)[I Is this a 24-Hour Reportable Event (Yes /No)? - 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Please elaborate on the choice(s) selected:

0

[]

0 Completed alcohol test. When informed that the sample was required under direct Refusal to Cooperate Other observation the donor refused to cooperate.

0 0[I Management Actions - 26.717(b)(8)

Disciplinary Action Permanent Denial Reason(s) for the Action (select all that apply):

[I MRO Confirmation 0 First drug or alcohol positive 0

Resignation/Withdrewal M Subversion 0

Second drug or alcohol positive 0

Subsequent positive test result from testing O Misuse

[

Violation of 5-hour abstinence rule E] Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be penformed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I

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C NRC FFD Program Performance Data Reporting System Single Positive Test Form

~ne Help Optional Reference Number for Licensee Use ISingle Form 2009 6 BG Q Sub I

1) All fields are required except those marked "optional'.
2) Entries In some form fields may result In Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mmndd/yyyy)[03/0/2009 Select Facility

[Nine Mile Point 7

Reason for Testing - 26.717(b)(5)

Pe-Access Employment Type - 26.717(b)(3) lContractorNendor Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity lvalid Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

IMarijuana Use NRC Cutoff (Yes / NO)

Additional Substance (as applicable) 1Please select Use NRC Cutoff (Yes / No

)'

Drug Testing Urine Additional Substance (as applicable)

IPlease Select Use NRC Cutoff (Yes / No) Yes Is this a 24-Hour Reportable Event (Yes / No)?- 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Please elaborate on the choice(s) selected:

0 01 First sample provide out of acceptable temunerature runoe, second samosle collected under Refusal to Cooperate 0

Other 01 Idirect observation.

Management Actions - 26.717(b)(8)

Disciplinary Action Permanent Denial Reason(s) for the Action (select all that apply):

E] MRO Confirmation 0

First drug or alcohol positive 0

Resignation/Withdrawal 10 Subversion 0

Second drug or alcohol positive 0

Subsequent positive test result from testing 0

Misuse 0

Violation of 5-hour abstinence rale 0

Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

[ptveoLaC 1Send Report to NRC1 1ý Print this Report Single Poslre T-t ro vmrsio 1.1.26

NRC FFD Program Performance Dataý Reporting System Single Positive Test Form OnlineHelp Optional Reference Number for Licensee Use 1Single Form 2009 7 GL Q Sub Note:

1) All fields are required except those marked 'optional'.
2) Entries In some form fields may result in Information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yyyy) IlI0/2009Z Select Facility INine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3)

FCOntractorNendOr Labor Category - 26.717(b)(3)

[Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported

[Drug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

[Marijuana I

Please Select Drug Testing IUrine Additional Substance (as applicable)

Please Select I

Use NRC Cutoff (Yes / No) Yes Use NRC Cutoff (Yes I NO) *"T I*

Use NRC Cutoff (Yes / No)'F*e7il Is this a 24-Hour Reportable Event (Yes/ No)? - 26.719(b) [No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Please elaborate on the choice(s) selected:

S01 rFirst sample was provide out of acceptable Itemeereture ranne, second sumnie obtained I

Refusal to Cooperate 0

Other E0 Under direct observation.

Management Actions - 26.717(b)(8)

Disciplinary Action Femanent Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation 0] First drug or alcohol positive.

0 Resignation/Withdrawal H Subversion 0 Second drug or alcohol positive 0

Subsequent positive test result from testing O Misuse 0 Violation of 5-hour abstinence rule

[] Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entdes needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I

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PUSARC 0lctoi Inomto Exchange NRC FFD Program Performance Dat Single Positive Test Fo a Reporting System Optional Reference Number for Licensee Use ISingle Form 2009 8 JB D Select Facility INine Mile Point rr I

Reason for Testing - 26.717(b)(5)

IPre-Access Employment Type - 26.717(b)(3)

IContractorNendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes INo)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable) lCocaine I

Please Select noOnH

1) All fields are required except those marked 'optional'
2) Entries in some form fields may result In Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Data of Collection (mm/dd/yyyy)

Drug Testing jUrine Additional Substance (as applicable)

Please Select Use NRC Cutoff (Yes / No)I Use NRC Cutoff (Yes I No)I'"

Use NRC Cutoff (Yes / No)'Yes Is this a 24-Hour Reportable Event (Yes /No)?- 26.719(b) No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors r0 0

Refusal to Cooperate El Other 0l Management Actions - 26.717(b)(8)

Disciplinary Action 1 -Year Denial Reason(s) for the Action (select all that apply):

El MRO Confirmation 0

First drug or alcohol positive 0

Resignation/Withdrawal 0

Subversion 0

Subsequent positive test result from testing O

Misuse 0

Violation of 5-hour abstinence ule o Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

[-SavetoL.*/-PC I*Send Report toNRC-Rp Single Posive Test Fom verson 1.1.26

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6 NRC FFD Program Performance Data Reporting System Single Positive Test Form i Online Help Optional Reference Number for Licensee Use ISingle Form 2009 9 JC D Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type-26.717(b)(3) iContractorNendor Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes I No)?

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 N]

Substance - 26.717(1b)(2) & (b)(4)

Additional Substance (as applicable)

Marijuana I

Please Select Note..

1) All fields are required except those marked 'optional'.
2) Entries in some form fields may result in information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yyyy)0222009 Drug Testing lUrine Additional Substance (as applicable)

]Please Select Use NRC Cutoff (Yes / No)II*

Use NRC Cutoff (Yes / No)rY'iI Use NRC Cutoff (Yes / No)Y Is this a 24-Hour Reportable Event (Yes /1No)?- 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0

0 Refusal to Cooperate Other Management Actions - 26.717(b)(8)

Disciplinary Action 1 - Year Denial Reason(s) for the Action (select all that apply):

EO MRO Confirmation 0

First drug or alcohol positive 0 Resignation/Withdrawal O] Subversion 0 Subsequent positive test result from testing o Misuse 0 Violation of 5-hour abstinence rule E] Other:

[

Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document l

to Send Report tN I

tthis Report*

Single Pwieve Test Foe vem ion 1.1.26

NRC FFD Program Performance Data Reporting System Single Positive Test Form Onlin elp-p Optional Reference Number for Licensee Use ISingle Form 2009 10JF D Select Facility Note:

1) All fields are required except those marked 'optional'.
2) Entries in some form fields may result In information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works property.

Date of Collection (mrnddly)0 INine Mile Point Reason for Testing-26.717(b)(5)

Pre-Access

]

Employment Type, 26.717(b)(3)

ContractorNendor I

Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported Drug Only Was this collection observed (yes No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

Marijuana ilease select I

Dreg Testing lUrine Additional Substance (as applicable)

JPlease Select Use NRC Cutoff (Yes / No)-Yes Use NRC Cutoff (Yes / No) I'Y _7 Use NRC Cutoff (Yes / No)'-III Is this a 24-Hour Reportable Event (Yes / No)? - 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0

n Refusal to Cooperate Other o]

0 Management Actions - 26.717(b)(8)

Disciplinary Action 1-Year Denial Reason(s) for the Action (select all that apply):

o] MRO Confirmation 0

First dreg or alcohol positive E] Resignation/Withdrawal o

Subversion

[I Subsequent positive test result from testing If Misuse 0

Violation of 5-hour abstinence rule

[] Other:

[] Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entdes needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document II I Save o'aPC l [

Report Ptont Nis R epo.

Single Pmw Twlt F version 1r..26

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6 NRC FFD Program Performance Data Reporting System Single Positive Test Form

~ne Help Note.

1) All fields are required except those marked 'optional'
2) Entries In some form fields may result In information Optional Reference Number for Licensee Use Single Form 2009 11 CL D being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3)

Contractor/Vendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

I Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity lValid Test Type(s) for Result(s) Reported IDrug Only 7

Was this collection observed (Yes/ No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable) lCocaine I

~lpease Select Date of Collection (mmldd/yyyy) 03/1/2009 Drug Testing Additional Substance (as applicable)

IPlease Select Use NRC Cutoff (Yes / No)*

Use NRC Cutoff (Yes I No)

]

Use NRC Cutoff (Yes / No) Ye Is this a 24-Hour Reportable Event (Yes /1No)? - 26.719(b) No Subversion Attempts - 26.7 17(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors Refusal to Cooperate Other o

11 Management Actions - 26.717(b)(8)

Disciplinary Action 1 - Year Denial Reason(s) for the Action (select all that apply):

E] MRO Confirmation 0

First drug or alcohol positive 0 Resignation/Withdrawal 0

Subversion 0 Subsequent positive test result from testing 0 Misuse 0 Violation of 5-hour abstinence rule El Other.

[

Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the isignature box and selecting "Clear Signature".

Cikto Digitally Sign This Document I

-Sv to Lo 1

P ISend Reprtto RC I

PrntthisReport Single Polttve Test For-ve-ion 1.1.26

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NRC FFD Program Performance Data Reporting System Single Positive Test Form Online Help Optional Reference Number for Licensee Use ISingle Form 2009 12 RM A Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Accessll Employment Type - 26.717(b)(3)

IContractor/vendor I

Labor Category - 26.717(b)(3)

IMaintenance (Craft)

Refusal - 26.717(b)(7) & 26,75 Was this collection refused (Yes / No)? N.

Test Results - 26.717(b)(4)

Test Validity Not Applicable Test Type(s) for Result(s) Reported Alcohol Testing Alcohol OnlyBreath Was this collection observed (Yes /No)? - 267J17(b)(7) & 26.1 N.

Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

Alcohol Please Select Note:

1) All fields are required except those marked 'optional'.
2) Entries In some form fields may result In Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yywlI)037/2009 Additional Substance (as applicable)

Please Select Use NRC Cutoff (Yes / No)

Z Use NRC Cutoff (Yes / No)

Z Use NRC Cutoff (Yes / No)Y Is this a 24-Hour Reportable Event (Yes/No)? - 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 171 0

Refusal to Cooperate 0

Other 0

Management Actions - 26.717(b)(8)

Disciplinary Action I -Year Denial Reason(s) for the Action (select all that apply):

[] MRO Confirmation I@ First drug or alcohol positive

[0 Resignation/Withdrawal o Subversion

[0 Subsequent positive test result frmm testing

[

Misuse E] Violation of 5-hour abstinence rule E] Other:

[3 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be l

performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Cikto Digitally Sign This Document I paet ojC JSendl Repcit to NRC I I PM isRap 8Snitr Postv Test Fon-version 1.1 +26

U. S.

N R

C NRC FFD Program Performance Data Reporting System Single Positive Test Form

1) All fields are required except those marked 'optional" Optional Reference
2) Entries in some form fields may result in information OptionalReference NumberforLicenseeUse Single Form 200913 FP D being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3)

ContractorNendor I

Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)? No Test Results - 26.717(b)(4)

Test Validity lValid Test Type(s) for Result(s) Reported FDrug Only Was this collection observed (Yes I No)? - 26.717(b)(7) & 26.1 Substance - 26.717(tb)(2) & (b)(4)

Additional Substance (as applicable)

IMarijuana Pease Select Date of Collection (mrnddl/yyyi)I2 200 I

Drug Testing

[0rine Additional Substance (as applicable)

Please Select Use NRC Cutoff (Yes / No) m Use NRC Cutoff (Yes / No)I'-

Use NRC Cutoff (Yes / No) Ye Is this a 24-Hour Reportable Event (Yes /No)?- 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

It this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors o1 0

Refusal to Cooperate Other o]

03 Management Actions - 26.717(b)(8)

Disciplinary Action I1-Year Denial Reason(s) for the Action (select all that apply):

I]

MRO Confirmation 1@ First drug or alcohol positive 0 Resignation/Withdrawal O Subversion

[] Subsequent positive test result from testing 1

Misuse 0 Violation of 5-hour abstinence rule 0] Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any enties needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

[

e tom Po C Sel nReo rtt thios Ne Single PsNitive Tent Fn version 1.1.26

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0opinp NRC FFD Program Performance Data Reporting System Single Positive Test Form On Ine l

Optional Reference Number for Licensee Use 1Single Form 2009 14 JR D Select Facility Nine Mile Point Reason for Testing - 26.7t17(b)(5) 1Pre-Access]

Employment Type - 26.717(b)(3)

Contractor/Vendor I

Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)? o Test Results - 26.717(b)(4)

Test Validity lValid Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes / No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicab Marijuana

]

Please Select

1) All fields are required except those marked 'optional'
2) Entries in some form fields may result in information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/dd/yyyy)0 9/2009 Drug Testing jUrineI le)

Additional Substance (as applicable)

Please Select I

Use NRC Cutoff (Yes / No)[

Use NRC Cutoff (Yes / No)l' Use NRC Cutoff (Yes / No)s Is this a 24-Hour Reportable Event (Yes / No)?- 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or mom of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0

11 Refusal to Cooperate Other 11 01 Management Actions - 26.717(b)(8)

Disciplinary Action 1 -Year Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation Eg First drug or alcohol positive

[] Resignation/Withdrawal o Subversion 0

Subsequent positive test result from testing O Misuse E] Violation of 5-hour abstinence rule

[] Other:

[] Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entdes needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking ]the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I I savto°P d'SendReport

°to NRCl I nipo SWoe Porute Tes Fo versson 1.1.26

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C

  • 6 NRC FFD Program Performance Data Reporting System Single Positive Test Form Online Help Optional Reference Number for Licensee Use ISingle Form 2009 15 MS 0 Select Facility Nine Mile Point I

Reason for Testing - 26.717(b)(5) lPre-Access

}

Employment Type - 26.717(b)(3)

ContractorNendor I

Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity lValid Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes /No)?- 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as Marijuana

]

Please Select

1) All fields are required except those marked 'optional'.
2) Entries in some form fields may result In Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works property.

Date of Collection (mm/ddyyyy)

/2009 Drug Testing Fur, ne applicable)

Additional Substance (as applicable)

]

lPlease Select Use NRC Cutoff (Yes / No)

Use NRC Cutoff (Yes / No)l Use NRC Cutoff (Yes / No) Ye Is this a 24-Hour Reportable Event (Yes /No)? - 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors

[]

01 Refusal to Cooperate Other M

0 Management Actions - 26,717(b)(6)

Disciplinary Action 1-Year Denial Reason(s) for the Action (select all that apply):

[I MRO Confirmation

[

First drug or alcohol positive

[3 Resignation/Withdrawal

[I Subversion

[I Subsequent positive test result from testing

[3 Misuse 0

Violation of 5-hour abstinence rule 0

Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC, Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all eror have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I

~avetoLocalPCI SendReport tNRC]

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e Posve eW F.r.m -eon 1.1.28

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S.~e~i NRC FFD Program Performance Data Reporting System Single Positive Test Form, Online Help Optional Reference Number for Licensee Use ISingle Form 2009 16 JS A I) All fields are required except those marked 'optlonal.

2) Entries In some form fields may result In Information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/ddyyyy)w/7/009 Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3)

ContractorNendor Labor Category-26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity Not Applicable Test Type(s) for Result(s) Reported Alcohol Testing Alcohol Onlyreath Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2)'& (b)(4)

Additional Substance (as applicable) iplease Select Use NRC Cutoff (Yes / No)I*]

Additional Substance (as applicable)

IPlease Select Use NRC Cutoff (Yes / No)Y Use NRC Cutoff (Yes / No)

Is this a 24-Hour Reportable Event (Yes /1No)? - 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0

[0 Refusal to Cooperate 11 Other 0

Management Actions - 26.717(b)(8)

Disciplinary Action 1-Year Denial Reason(s) for the Action (select all that apply):

[I MRO Confirmation 19 First drug or alcohol positive 0 Subversion 0 Misuse 0

Violation of 5-hour abstinence rule E] Sale, Use or Possession in PA 0 Resignation/Withdrawal

[

Subsequent positive test result from testing 0

Other:

This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the User digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed. changes only can be made to the form by first removing your signature by right-cl icking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I

[*Save~to LcalP-C I [end Report t6 NRC PrthintRePod, single Posive Test Form version 1.1.26

i 4V

-I-tern I*ep3 0y/

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NRC FFD Program Performance Data Reporting System Single Positive Test Form Online Help Optional Reference Number for Licensee Use ISingle Form 200917 JS D Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3) lContractorNendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes I No)?

Test Results - 26.717(b)(4)

Test Validity lValid 7

7 Test Type(s) for Result(s) Reported Drug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

Marijuana piea Se lect

1) All fields are required except those marked 'optional'
2) Entries In some form fields may result In Information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mmndd/yyyy) [0/2009 Drug Testing lUrine Additional Substance (as applicable) 1Please Select 3

Use NRC Cutoff (Yes a No)Y Use NRC Cutoff (Yes / No)

Use NRC Cutoff (Yes / No)IY.'

Is this a 24-Hour Reportable Event (Yes /No)?- 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0

0 Refusal to Cooperate 01 Other 01 Management Actions - 26.717(b)(8)

Disciplinary Action i -Year Denial Reason(s) for the Action (select all that apply):

E] MRO Confirmation 0

First drug or alcohol positive 0 Resignation/Withdrawal r] Subversion 0 Subsequent positive test result from testing o

Misuse 0 Violation of 5-hour abstinence rule

[0 Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

-rav-itL*-c FC_

IsendRep°ort fo-NRC I nIttiReIýrt Single Poitive Test For-versIon 1.1.20

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1) All fields are required except those marked optional'
2) Entries In some form fields may result In Information Optional Reference Number for Licensee Use Single Form 2009 18 CS D being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3) iContractor/vendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity Test Type(s) for Result(s) Reported jDrug Only Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

IMarijuana I

IPlease Select I

ate of Collection (mmndd/yyyy)01/2009 Drug Testing 10rine Additional Substance (as applicable) jPlease Select Use NRC Cutoff (Yes / No) es Use NRC Cutoff (Yes / No)*

Use NRC Cutoff (Yes / No)'

Is this a 24-Hour Reportable Event (Yes /1No)?- 26.719(b)

No Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed ActionslBehaviors O1 01 Refusal to Cooperate Other o3 0

Management Actions - 26.717(b)(8)

Disciplinary Action I1" Year Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation M First drug or alcohol positive

[I Resignation/Withdrawal o

Subversion

[I Subsequent positive test result frm testing E0 Misuse 0

Violation of 5-hour abstinence rule 0

Other:

0 Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document I Save to Locl PC ISend Report to NRC f

tWis Report Singil P-itfe Tist Foee v-ion 1.1.26

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1.

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S S.C NRC FFD Program Performance Data Single Positive Test Form Optional Reference Number for Licensee Use [Single Form 2009 19 FS D Select Facility INine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access l

Employment Type - 26.717(b)(3)

IContractorNendcor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity IValid Test Type(s) for Result(s) Reported FDrug Only Was this collection observed (Yes /No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

ICocaine IIPlease Select Reporting System

1) All fields are required except those marked 'optional'.
2) Entries In some form fields may result In Information being auto-populated into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works properly.

Date of Collection (mm/ddlyyyy)00/2009 I

Drug Testing

[Urine]

Additional Substance (as applicable)

IPlease Select

]

Use NRC Cutoff (Yes / No)Ye Use NRC Cutoff (Yes / No)*

Use NRC Cutoff (Yes / No) Yes Is this a 24-Hour Reportable Event (Yes /1No)?- 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 11 El Refusal to Cooperate 03 Other 0

Management Actions - 26.717(b)(8)

Disciplinary Action i -Year Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation

[] First drug or alcohol positive 0

Resignation/Withdrawal 0 Subversion 0

Subsequent positive test result from testing 0

Misuse 0

Violation of 5-hour abstinence rule 0

Other:

[] Sale, Use or Possession in PA This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the form cannot be signed until all errors have been resolved, After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking,the signature box and selecting "Clear Signature".

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S1f~l eii 0h-Eibwiiel NRC FFD Program Performance Data Reporting System Single Positive Test Form Online Help Optional Reference Number for Licensee Use ISingle Form 2009 20 WY D

1) All fields are required except those marked 'optional'
2) Entries In some form fields may result In Information being auto-populated Into other form fields.
3) Use Adobe Reader 9.3 to ensure this form works property.

Date of Collection (mmldd/yyyy)0

/2009 Select Facility Nine Mile Point Reason for Testing - 26.717(b)(5)

Pre-Access Employment Type - 26.717(b)(3)

ContractorNendor Labor Category - 26.717(b)(3)

Maintenance (Craft)

Refusal-26.717(b)(7) & 26.75 Was this collection refused (Yes / No)?

Test Results - 26.717(b)(4)

Test Validity lValid]

Test Type(s) for Result(s) Reported Drug Only 1

Was this collection observed (Yes/No)? - 26.717(b)(7) & 26.1 Substance - 26.717(b)(2) & (b)(4)

Additional Substance (as applicable)

Marijuana IPlease Select Drug Testing lUrine Additional Substance (as applicable)

[Please Select Use NRC Cutoff (Yes / No)rYes Use NRC Cutoff (Yes I No)

I Use NRC Cutoff (Yes I No)l'*

Is this a 24-Hour Reportable Event (Yes / No)? - 26.719(b)

Subversion Attempts - 26.717(b)(7) and 26.75(b)

If this result relates to a subversion attempt, select one or more of the following choices as applicable.

If not a subversion attempt, do not select any of the four boxes.

Physical Evidence Observed Actions/Behaviors 0]

E0 Refusal to Cooperate 01 Other

[]

Management Actions - 26.717(b)(8)

Disciplinary Action 1-Year Denial Reason(s) for the Action (select all that apply):

O MRO Confirmation

[

First drug or alcohol positive O Subversion o Misuse 0

Violation of 5-hour abstinence rule 0

Sale, Use or Possession id PA O Resignation/Withdrawal o

Subsequent positive test result from testing O Other:

This report must be digitally signed before it can be sent to NRC. Click on the empty box below to sign this report. A data validation check will be I

performed when the user digitally signs the form. Any entries needing correction will be highlighted in red and the furm cannot be signed until all errors have been resolved. After the report has been digitally signed, changes only can be made to the form by first removing your signature by right-clicking the signature box and selecting "Clear Signature".

Click to Digitally Sign This Document

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