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

~* 1 LJ S N p ( ' ' FF D Prog ram Perfo,rn a1ce Data Report ng System

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1) All fields requlrttd ucepr those marlf.ttd 'optlonar APPROVED BY 0MB: CLEARANCE NO. 3150-G146 EXPIRES: 04130/2021

2) Entries in some fields auto-populate Information in other fields Estimated burden per response to compty v.ill llis coUection request is 30 n'inutes. This

3) Mouse over form fields lo view additional information fo,m is a voh.mtaiy means of reporting the Information required under 10 CFR 26.417(b)(2)

4) Use of Adobe Reader I or later is required 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, Submission D Update 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 Uni ue Reference ID Licensee Su lied of Management and Budget, Washington DC 20503. If a means used to irr.,ose PAL-2019-03 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 Facility I Palisades [50-255) Date of Collection (mmldd/yyyy)

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212012019 I

Reason for Testing - 26.717(b)(5) Pre-Access Testing Reason (optional) Please elaborate (optional)

!Pre-Access j1nitial Authorization Oay and Zimmerman-Craft Employment Type - 26 717(b)(3) Outage Worker (optional)?

IContractorNendor INo Labor Category - 26.717(b)(3)

I Maintenance (general lacil~y)

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 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_ _~

Management Actions

• 26 717(b)(8) & 26 75 Please elaborate on the Reason tor the Action Reason for the Action Wlful Omission/Falsification ol Program Oisqua1ifying Information

!Other 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_*--~~=----~11Ls_u_m_....,_*_.----c===----~l lAA/FFD Super,,so 1 First Name Last Name J Hu1M1el@ente1gy.com

~--~P~o-s~itio~n:Ti~tl-e---~ ----=c-om-pa-n-y""E""m-a°"il,.,A,...dd,..,...n,-s-s---

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 ISave to Local PC I! Print this Report  !

Single Positive Tes! Fonn (version 1.8 0 - Apnl 2018) NRC Fann 890 (12/2014)