ML20063J273

Single Positive Test Form Collected on 09/26/2019

ML20063J273
Person / Time
Site:	Wolf Creek
Issue date:	02/13/2020
From:	Black P Wolf Creek
To:	Office of Nuclear Reactor Regulation, Office of Nuclear Security and Incident Response
Shared Package
ML20063J382	List: ML20063J228 ML20063J232 ML20063J234 ML20063J237 ML20063J240 ML20063J247 ML20063J252 ML20063J265 ML20063J273
References
A1-19, RA 20-0016
Download: ML20063J273 (1)

Text

• , U.S.N RC ' FFD Program Performance Data Repo1ting System

"-., NRC Fo1111 f~,c S 1',Jle Po:o,t .re T,q forrn 1

I I I~ J I 1 , II / 11,, f I II 1"

1) AR flolda nq,,,_, uce,,t lhoH "**°" 'opt/oMI' APPROVED BY 0MB: CLEARANCE NO. SII0.0141 EXPIRES: IM/S0/2021 2J Entrlea In aome tfe/da *ufO.popul*te lnlormallon In ofher "-'* E1tim1ted burden per response to comply with this collection request la 30 minutes. This

1) Mouse ovw form ffeld* to view adtMlonlll lntom.tlon form It a voluntary means of reporting the information required under 10 CFR 26.4'17(b)(2)

4) U.* of Adobe RNder I or later I* reqult'N and 26 .717. The Information II required by NRC to obtain on en annual basis ttt:e specific tttnesa-for-duty (FFO) program performance data on drug and alcohot proguma from licensees and ot,er entitles. Send comments regarding burden estimate to lhe FotA, D Submission Update Privacy and lnfonnation Collection Branch (T5-F53), U.S. Nudear Regulatory Comrriuion, Washington DC 2055~01 , or by e-mal to lofpcolccg. BeaouraONBC ggy 1111d to the Desk Officer, Office of Information and Regulatory Affairs, NEOB--1020, (3150-0146), Office Un/gH Rer.ranc* ID (Licensee Supplied)

IA1-19 I of Management and Budget, Washington DC 20503 . If

• means used to Impose Information collection does not chplay a currenlty valid 0MB control number, the NRC may not conckJd or sponsor, and

• perwon la not re~ed to respond to, the Information

~lection.

Faclllty 1Wo~ Creek [50-482] Date of Collection (mm/dd/yyyy)

I 09/26/20 19 I Re.sot1 for Tut.Ing - 26.717(b)(5) Please elaborate (optional)

._IR_*nd_om _ _____ _JJ l ' - - - - - - - - - - - - - - - - - - - - - - - - - - ' I Employment Type - 26.717(b)(3) Dutage Worl<er (Opt/O<JaQ?

11..icenHe Employee !No ubor Category - 26.717(b)(3)

I* thl*

• U-hour reportable*"""' under 2S.719(b)? ~

WH this collection rafused? - 26.717(b)(7) & 26.75 ~

Tut Ruulls - 26.717(b)(4)

Test Type{s) for Result(s) Reported - 26.717(b)(2)

IAk:ohol Only Subatane<i - 26.717(b)(2) & (b)(6)

Alcohol Specimen Tested

'Breath

'Mlat 26.103 BAC levet was exceeded?

l o .03 and in WOii< status at least 1 hr Subwrslon Atfflmpt - Did this collection involve a subversion attempt? - 26.717(b)(7) and 26. 75(b) LI_ _ _ N_o_ _...J M*n*g*m- Action* - 26.717(b)(8) & 26.75 Reason for the Action I First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated)

INRC Minimum Specific Sanction Applied 114- Day Denial Person(*) Ruponalbl* for lnformlllfon Provided Penon 1 (required):

LIP_""'__e_LA_--=,,.....,=-

First Name

- --~' '~BLACK - - - -Las - t_N_ame IFess sPecw.1sr

__. Position TIiie PABI..ACKCIIWCNOC .COM Company Email Address Penon 2 (opilonll):

L'SONY--A---.====---~I ~----Lasi--N-.------'

Flr1l Name IJoNES I JsUPERVISOR ACCESS SCREENING Position Trtle I SOJONESClll'\ICNoc.cOM Company Email Address Final SNp (Required). NRC will con alder lhia lom1 authenllc In 1coordance with 10 CFR 28,11 onty when lhe -..,alldate & Lock-9 button hi dicked and 111 effort (highlighted In red) have been c01Teeted. The "Validate & Lock* button will change to *Locked* after the data valldation process has been successfully completed Indicating the form 11 ready for submission.

- Fonn Locked On:!Feb 13, 2020 at 5:52:31 PM ISave to Local PC !I Print this Report !

Single Positive Test Form (version 1.8.0 - Apnl 2018) NRC Fonn 890 (1212014)