ML20057C819

Single Positive Test Form Collected on 02/20/2019

ML20057C819
Person / Time
Site:	Palisades
Issue date:	02/24/2020
From:	Summers S Entergy Nuclear Operations
To:	Office of Nuclear Security and Incident Response
Shared Package
ML20057C816	List: ML20057C817 ML20057C818 ML20057C819 ML20057C822 ML20057C824 ML20057C826 ML20057C828 ML20057C829
References
PAL-2019-03
Download: ML20057C819 (1)

Text

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FFD Program Perfo,rna1ce Data Report ng System

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NRC fo,m 890 S1r gle Pos.!,e Tes, For*11

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1) All fields requlrttd ucepr those marlf.ttd 'optlonar

2) Entries in some fields auto-populate Information in other fields

3) Mouse over form fields lo view additional information

4) Use of Adobe Reader I or later is required D

Submission Update Uni ue Reference ID Licensee Su lied PAL-2019-03 Facility I

Palisades [50-255)

APPROVED BY 0MB: CLEARANCE NO. 3150-G146 EXPIRES: 04130/2021 Estimated burden per response to compty v.ill llis coUection request is 30 n'inutes. This fo,m is a voh.mtaiy means of reporting the Information required under 10 CFR 26.417(b)(2) and 26 717 The information is required by NRC to obtain on an annual basis site specdie fitness-for-duty (FFO) program performance data on drug and alcohol programs from licensees and other entities. Send comments regarding burden estimate to the FOIA, Privacy and Information Collection Branch (T5-F53), U.S. Nudear Regulatory Commission, Washington DC 20555-0001, or by e-mail to fOlocaltcll1,Rt:AAIMft#:NRCoov. and to the Desk Officer, Office of Information and Regulatory Affairs. NEOB-1020, (3150-0146), Office of Management and Budget, Washington DC 20503.

If a means used to irr.,ose information colection does not cfisplay a currently vaid 0MB control number, lhe NRC may not conduct or sponsor, and a person is not required to respond to, the information collection Date of Collection I ~

212012019 I (mmldd/yyyy)

Reason for Testing - 26.717(b)(5)

!Pre-Access Pre-Access Testing Reason (optional)

Please elaborate (optional)

Employment Type - 26 717(b)(3)

IContractorNendor Labor Category - 26.717(b)(3)

I Maintenance (general lacil~y) j 1nitial Authorization Outage Worker (optional)?

INo Is this a 24-hour reportable event under 26.719(b)? ~

Was this collection refused?

• 26 717(b)(7) & 26 75 ~

Test Results - 26.717(b)(4)

Test Type(s) for Resl.il(s) Reported - 26 717(b)(2)

!Alcohol Only Oay and Zimmerman-Craft Substance. 26 717(b)(2) & (b)(6)

Alcol1ol Specimen Tested I

Breath I

'Mlat 26 103 SAC level was exceeded?

lo 04 or greater Subversion Attempt - Did this collect1on involve a subversion attempt? - 26 717(b)(7) and 26 75(b) ~I ___

N_o __ ~

Please elaborate on the Reason tor the Action Management Actions

• 26 717(b)(8) & 26 75 Reason for the Action

!Other Wlful Omission/Falsification ol Program Oisqua1ifying Information Sanction Applied (NRC Minimum or Licensee Administrated) lucensee Administrated Specific Sanction Applied 15-Year Denial Person(s) Responsible for Information Provided Person 1 (required).

I Ls_co_*--~~=----~11 Ls_u_m_....,_*_.----c===----~l lAA/FFD Super,,so 1

J Hu1M1el@ente1gy.com First Name Last Name

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Person 2 (opUonaJ):

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First Name Last Name Position Title Company Email Address Final Step (Required)

• NRC will cons!der this form authentic Jn accordance with 10 CFR 26.11 onty when the 'Vatidate & Lock" button is dicked and all 1,rors (highlighted in red) have been corrected. The "Validate & Lock* button will change to 'Locked" after lhe data validation process has been successfully completed indicating the form is ready for submission Form Locked On. !Feb 24, 2020 at 3.44.58 PM Single Positive Tes! Fonn (version 1.8 0 - Apnl 2018)

I Save to Local PC I ! Print this Report !

NRC Fann 890 (12/2014)