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Category:License-Fitness for Duty (FFD) Performance Report
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FFD Program Performance Data Reporting System Single Positive Test Form (EIE General Submission Portal)
Note:
Submission Delete 1) All fields are required except those marked 'optional'.
Update Submission 2) Entries in some form fields may result in information being auto-populated into other form fields.
Unique Reference Number (Licensee Supplied)
- 3) Use Adobe Reader 8 or later for this form to work properly.
589758H 4) Hold your mouse over a form field to view additional information.
Select Facility Duane Arnold [50-331] Date of Collection (mm/dd/yyyy) 02/11/2014 Reason for Testing - 26.717(b)(5) Please elaborate (optional)
Random Employment Type - 26.717(b)(3)
Licensee Employee Please elaborate Labor Category - 26.717(b)(3)
Nuclear Analyst.
Other Refusal - 26.717(b)(7) & 26.75 Was this collection refused (Yes / No)? No Test Results - 26.717(b)(4)
Test Validity Not Applicable Test Type(s) for Result(s) Reported - 26.717(b)(2) Alcohol Testing Alcohol Only Breath Substance - 26.717(b)(2) & (b)(6)
Alcohol What 26.103 BAC level was exceeded?
0.03 and in work status at least 1 hr Is this a 24-Hour Reporting Event (Yes/No)? - 26.719(b) No Subversion Attempts - 26.717(b)(7) and 26.75(b)
Did this collection involve a subversion attempt (Yes/No)? No Management Actions - 26.717(b)(8) & 26.75 Reason for the Action First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated)
NRC Minimum Specific Sanction Applied 14- Day Denial Person(s) Responsible for Information Provided Person 1 (required):
Lisa Alvarez MROA lisa.alvarez@fpl.com First Name Last Name Position Title Company Email Address Person 2 (optional):
David Bonthron AA/FFD Program Manager david.bonthron@fpl.com First Name Last Name Position Title Company Email Address Final Step (Required) - NRC will consider this form authentic in accordance with 26.11 only when the Validate & Lock button has been selected and all errors (i.e., those highlighted in red) have been corrected. The Validate & Lock button will change to Locked after the data validation process has been successfully completed and the form is ready for submission.
Locked Form Locked On: Jun 11, 2014 at 10:06:53 AM Save to Local PC Print this Report Single Positive Test Form (version 1.5.0 - January 1, 2014)