ML20217C328

Rev 1 to Security Dept Procedure IS-DP-00100, Bac Exams

ML20217C328
Person / Time
Site:	Davis Besse
Issue date:	11/09/1989
From:	Leny L CENTERIOR ENERGY
To:
Shared Package
ML20217C290	List: ML20217C284 ML20217C300 ML20217C307 ML20217C314 ML20217C320 ML20217C328 ML20217C340 ML20217C348 ML20217C357 ML20217C366 ML20217C381 ML20217C394 ML20217C400
References
IS-DP-00100, IS-DP-100, NUDOCS 9107150222
Download: ML20217C328 (24)

Text

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• g,E, DUCE TITLE SHEET .

tif ta wo 15-DP-00100 pfte Security Department *

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INIT14 T E D O V BAC Examinations 1 Januarv 3, 1990 C. E. Woods sueaan osa aremovio e v sos. . a cie.co.<i IS-DP-00100 Revision 00 N/A Prepared By: -

d4N N4 Date // /f 7

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Sponsor  : & Date //

Supervisor - Nuclear Security Support Approved By: / M Date // /

Mafiager - ndustrial Security

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ONLY - .._,

Procedure Classification:

Safety Related 1

Quality Related X Non-Quality Related l

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i o se ein CAGE CEVISION PCOCEDUCE NUM8tQ DAVIS.8 ESSE ADMINLSTRATIVE PROCEDURE BAC Examinations 2 01 IS-DP-00100 C-2

., List or ErrECTIVE PAGES Pace Chance No._ Pace __ Chance No._ Pace Ch a nag _t[qw ,

1 2 C1,C2 3

4 j i

5 l 6

7 j 8

9 10 _ C1,C2 i

11 _

12 _

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14 _ C-2 15 _ C-1 16 _

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es nn DAVIS SESSE ADMIMSTRATIVE PROCEDURE COGE Civ*oN PaoCEDUCE Nuvetn BAC Exam'inations 3 01 IS-DP-00100 TABLE OF CONTENTS 1.0- PURPOSE .......................................... 4 2.0 APPLICABILITY / SCOPE .............................. 4  !

3.0 REFERENCES

....................................... 4  :

4.0 DEFINITIONS ...................................... 4 RESPONSIBILITIES . ................................

1 5.0 5 6.0 PROCEDURE ........................................ 7 6.1 For cause Test Initiation ................... 7 6.2 Prerequisites ............................... B 6.3 Test Performance ............................ 9 6.4 Test Results ................................ 11 6.5 Confirmatory Test Initiation ................ 13 7.0 RECORDS . . ......................................... 17 ATTACHMENT 1: Justification For Not Performing a BAC Examination ............................. 18 ATTACHMENT 22 Alcohol.Related Investigation Report . . . . 19

-ATTACHMENT 3: Test Performance Report . . . . . ..... . 20 COMMITMENTS 21

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80 M4 PAGE mtvisioN PAoCf DUAt NUM8tM DAVIS SESSE ADMIN 6STRAT1VE PROCEDURE BAC E.Yaminations 4 01 IS-DP-00100 l

1.0 PURPOSE 1.1 To establish the requirements, responsibilities, and l processes to be used during the administration of breath alcohol detection examinations using the BAC Verifier. This procedure satisfies the requirements established in NG-IS-00004, Fitness for Duty program. l 30 APPLICABILITY / SCOPE This procedure applies to those personnel assigned the  !

responsibility for conducting confirmatory BAC Examinations and for-cause BAC examinations.

3.0 EEFERENCES 3.1 Develoemental l 3.1.1 E.E.I. Guide to Drug and Alcohol Policy 3.2 Irelementation l 3.2.1 NG-IS-00004, Fitness For Duty 3.2.2 NG-IM-60106, Nuclear Records Managment l I

3.2.3 IS-DP-00518, Reporting Requirements 3.2.4 IS-AC-00017, Denied Access List Control 4.0 DEFINITIONS 4.1 AVEOLAR AIR - Air from deep within the lungs as opposed to the upper regions of the lungs or mouth. Aveolar air provides a much more representative sample of breath alechol concentration.

4.2 BREATH ALCOHOL CONTENT - The percent of alcohol present in a po'. sons breath expressed as grams by weight in 210 liters of ,

deep lung breath.

4.3 BAC VERIFIER - The device used to collect breath samples for the purpose of determining blood alcohol concentration through breath analysis.

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ne nn DAWS-SSSSE AmeWesmAUVE PROC 800RE PAGE 08 V*0N PROCEDUM Nuusta >

i BAC Examinations 5 01 IS-DP-00100  !

I

'4.4 BAC SENIOR OPERATOR ~ An Individual who has satisfactorily {

completed a basic senior operator-training course and has '

' demonstrated that he/she can properly care for, maintain, ,

perform calibration checks upon, and operate the breath i testing instrument.  ;

4.5 - BAC TEST OPERATOR - An individual who has satisfactorily  !'

completed a basic operator training course and has demonstrated that he/she can properly-operate the breath testing instrument.

5.0 RESPONSIBILITIES l 5.1 General Supervisor - Nuclear Security Operations shall be j responsible fort  ;

t 5.1.1 Implementing and maintaining the requirements of.  !

this procedure.  :

5.1.2 Ensuring:that Alcohol Related Incident Reports are prepared-and processed fnr each individual that is -

requested to submit to a BAC Examination. '

5.2 Supervisor - Access Control shall be responsible for  !

ensuring that access authorization is denied those individuals whose breath alcohol concentration has been }

determined to be greater than acceptable limits, or has I refused to consent to submit to a RAC Examination. ,

5.3 Security Shif t Supervisor / Coordinator shall be responsible i fort 5.3.1 Either supervising the performance of BAC ,

Examinations, QR- ~

5.3.2 Performing.the functions of the BAC Verifier  !

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Operator.

L 5.3.3 Notifying the General Supervisor-Nuclear Security Operations and Supervisor-Access control whenever a BAC Examination is performed.

5.4 BAC Senior Operator _shall

. t 5.4.1 Meet the requirements for certification for the ,

State of Ohio.

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s senn Pact naviscN Pnoctovat NUMetR dam mWVE PROCEOung RAC Exar.inations 6 01 IS-DP-00100 l

5.4.2 conduct applicable simulator and/or calibration tests to ensure the %AC Verifier is functioning  ;

within acceptable tolerances. )

i 5.4.3 supervise the administration of the program and i performing maintenance of the EAC Verifier, as required.

5.4.4 Ensure RAC test solution is ordered. l 5.5 BAC Verifier Operator shall-be responsible fort 5.5.1 Performing BAC Examinations in accordance with this procedure.

1

5. 5. 2 ' Notifying the Security shift supervisor _whenever an I individual has been requested to submit to a BAc l Examination.

5.5.3 Infotaing.the individual that he/she has the right to union representation, or another witness to be present, during the administration of the BAC Examination. '

5 5.4 Ensuring that the individual submitting to a BAC Examination has consented,Lin writing, to the test.

5.5.5 Ensuring that RAC Examinations are performed under tha proper conditions established in this procedure.

5.5.6 Ensuring there is no smoking during the administration of-the examination.

5.5.7 Ensuring that there era no radio transmissions in the examination room.

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$$ttft DAVIS 4SESSE ADMINISTRATWE PROCEDURE FAGE f:EvtSION KOCEDumE Nuustm BAC Examinations 7 01 IS-DP-00100 6.0 PROCEDURE 9

,. t 6.1 for cause_TestiInitiatien j 6.1.1 Upon being notified that an individual appears to be under the influence of alcohol when the Medical Services Shift Supervisor shallt personnel arm not available the Security 1

a. Ensure the individual is escorted to the PPF. l b.

Make a determination as to whether a BAC Examination should be performed.

c. If the Security-Shift Supervisor makes the

determination to test, the initial observer

[ shall be instructed to report to the PPF. l

d. If the Security Shift Supervisor makes the determination NOT to test, he/she shall complete Attachment 1, Justification For Not Performing A BAC Examination, and forward it to the General Supervisor-Nuclear Security operations.

6.1.2 If the Security Shif t Supervisor determines that a test is to be conducted, he/sbe shall obtain the Test Subject's consent on section 1 of Attachment 2, Alcohol Related Investigation Report.

6.1.3 The initial observer shall be instructed to complete section 2 of Attachment 2. l 6.1.4 The Security' Shift Supervisor shall notify the Shift Supervisor ON-Shif t that a BAC Examination shall . be f conducted.

I -________________..._________ NOTE 6.1.5 '

In the event video tape equipment is not available a management witness.may be substituted.

l .__________________________ -

6.1.5' l The BAC Examination shall be administered and video taped in an area designated by the BAC Verifier-Operator.

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ID 96?9 PAGE Rtyl$loN PROCEDupt NUMBER davis.BESSE ADMINISTRATTVE PROCEDURE BAC Examinations 8 01 IS-DP-00100 6.1.6 Th1 Security Shif t Supervisor shall inform the BAC verifier operator (if other than him/herself) to perform the test and complete applicable sections of Attachment 2, and the Test Performance Report, Attachment 3.

NOTE 6.1.7 Individuals refusing to submit to BAC Examinations I are immediately denied Access.

6.1.7 The BAC Verifier Operator shall ensure that the Test subject's consent has already been obtained on section 1 of Attachment 2.

6.1.8 The unavailability of the requested representative l or witness shall not prevent the administration of i the BAC Examination. i 6.1.9 Individuals being tested shall be informed that they have the right to union representation or another witness to be present during the administration of  ;

the BAC Examination. '

6.2 Frerecuisites 6.2.1 Prior to performing the test, the BAC Verifier Operator _shall ensure that the test subject has had I no oral intake or regurgation of any material for 20 minutes.

6.2.2 The BAC Verifier Operator performing the BAC Examination shall:

I

......--______.............. 1 I

NOTE _6.2.2.a i

Section 1 of Attachment 2 should be completed prior l l to any other section's completion.  !

a. Verify that section 1, (Consent), of Attachment l 2 is completed prior to conducting the BAC l l Examination. l

b. Ensure section 2 Attachment 2, is completed.  !

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no.oi DAVIS.BESSE ADMINISTRATTVE PftOCEDURE PAGL nivisioN Faoctouxt Nvusta BAC Exam'inati?ns 9 01 lIspp.ootoo c.. Complete section 3 of Attachment 2. l 6.2.3 The security shift Supervisor shall notify the General Supervisor-Nuclear Security operations and supervisor-Access control any time a BAC Examination is conducted.

6.3 Test _Performanen 6.3.1 The individual performing the BAC Examination shalls

a. Complete section 1 Attachment 3. l

b. Verify that the BAC Verifier is in the oN position.

c. If the BAC Verifier is not in the ON position, plug the BAC Verifier cord into 115 VAC power source equipped with a surge protector.  !

d. Turn Pcwer CN/OFF Switch to ON.

e. observe time (hours and minutes) displayed in upper right display and three dashes in lower left display,

f. Allow unit to warm up for 10 to 20 minutes. (A longer warm-up is required if the BAC Verifier has been left in a cold environment).

g. observe that green ready light is lit and the l disappearance of the dashes on the lower left display, indicating the BAC Verifier is warmed-up and ready to run,

h. Insert the disposable mouthpiece into the l breath tube,

i. Press the RUN button. .

j. obsetve the BAC Verifier readying itself for the subject test. The following messages will display PUR, BLN and CAL.

k. observe the BLO message in the display.

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Pact PaoctDurt Nuustm VIS BESSE ADMIN 68TRATWE PROCEDURE j rtvisioN BAC Examinations 10 01 IS-DP-00100 cZ l.,. Instruct the individual to take a breath and blow normally into the mouthpiece. If the test is not initiated within two minutes the BAC '

Verifier will revert to the Ready To Run mode.

m. If the BAC reverts to the Ready To Run mode, GO To step 6.3.1.1.

n. Observe the Breath Alcohol Level displayed. C-2l

o. Set the timer for two minutes C-21

p. Wait at least two but no more than 10 minutes and take another breath test.

q. The test results shall be considered valid  !

if the result of each test is within plus or minus 10 percent of the average of the two tests, j l

r. If the test results are not valid, the l breath tests shall be repeated using a dif ferent evidentiary quality breath alcohol analysis device until test results are valid,

s. If the results of the first valid test l indicate less than 0.01 percent blood alcohol concentration, instruct the individual to return to work.

I

t. If the results of the first valid test indicate j a blood alcohol concentration of 0.04 ,

percent or greater GO To subsection 6.5, Confirmatory Test Initiation. l NOTE 6.3.1.u If the results are bewteen, or including, 0.01 and  !

0.039 wait 30 minutes, if the Health Center has not C-1 conducted the preliminary test, and retest the individual to see if the alcohol concentration is going up or down.

u. If the results of the tests are between, or include, 0.01 or 0.039 percent, Security shall coordinate the evaluation of whether the individual should be allowed to work in accordance with NG-IS-00004. j i

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DAVIS BESSE ADMINISTRATIVE PROCEDURE PoGt ctemoN rooctouCt NUMBER BAC Examin&tions 11 01 IS-DP-00100 l

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Remove the disposable mouthpiece,

w. Remove, sign, date, and attach the BAC printout to Attachment 3. l

x. Complete section 2 oi Attachment 3. l 6.3.2 Upon completion of the BAC Examination the  !

individual performing the examination shall:

a. Indicate in section 3 of Attachment 3 the l breath alcohol level identified by the BAC i Verifier. '

b. Sign and date section 3, of Attachment 3. I

c. Ensure that any witness (es) sign and date section 3 of Attachment 3.  !

6.4 Iest Resulta I 6.4.1 If DAC Verifier Test results are below specified limits a determination shall be made by the Security Shif t Supervisor and test subject's supervisor if any further actions are required in accordance with NG-IS-00004. l 6.4.2 The Security Shif t Supervisor shall notify the General Supervisor-Nuclear Security operations and Supervisor-Access control. I NOTE 6.4.3 j The two reports shall either be hand delivered or l j

placed in a sealed envelope marked " Confidential" and forwarded to the General Supervisor-Nuclear Security Operations.

6.4.3 If no further actions are taken, the Security Shift Supervisor shall forward to the General Supervisor-Nuclear Security Operations:

a. The original of Attachment 2. l

b. The original of Attachment 3 with the BAC l Printout attached.

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5 0 TOIS CAGE REvi5loN PROCEDURE NUMBE A DAVIS-SESSE ADMINtETRATTVE PROCEDURE BAC Examinations 12 01 IS-DP-00100 6.4.4 If. breath alcohol examination determines breath alc~ohol concentration to be 0.04 or greater, the Security Shift Supervisor shall deny access authorization and notify a responsible individual to escort the tested individual from Toledo Edison l property in accordance with section 4 of l' Attachment 3.

6.4.5 The Security Shift Supervisor shall make a reportability determination in accordance with IS-DP-00518. l 6.4.6 The individual's escort shall sign section 4 of l Attachment 3 to indicate acceptance of l [

responsibility for the tested individual.

NOTE _6.4.7 The forms shall either be hand delivered or placed in a sealed envelope marked " Confidential" and forwarded to the General Supervisor-Nuclear Security Operations.

6.4.7 The Security Shift Supervisor shall forward all applicable Forms to the General Supervisor-Nuclear Security operations.

6.4.8 The General Supervisor-Nuclear Security operations shall:

a. Review all the applicable forms.

b. Sign all the applicable forms,

c. Forward forms to the Supervisor-Access control for review and approval.

, 6.4.9 The Supervisor-Access Control shall evaluate the l results in accordance with NG-IS-00004 and make a l l determination as to whether the tested individual is added to the Denied Access List in accordance with IS-AC-00017. l 4

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-o e 80 Pett DAVIS SESSE ADMNSTRAffVE M10CIDung Pact tevisioN emoctount Nuusen BAC Exami' nations 13 01 IS-DP-00100 6.5- confirmatorv_ Test Initiation  !

6.5.1 Upon being notified that an individual requires N/

a confirmatory test the Security Shift Supervisor ,

shall

a. Ensure the individual is escorted to the PPF if  !

not already there.

b. Ensure the individual, has signed a consent form ,

at the. Health center or during the for cause testing process.

6.5.2 Prior to performing the test, the BAC Verifier

. operator shall observe the test subject for 20 ,

minutes to ensure oral intake of any material does not occur.

6.5.3 The Security Shift Supervisor shall notify the General Supervisor-Nuclear Security Operations and Supervisor-Access Control any time a confirmatory

+

BAC Examination is conducted.

6.5.4 The individual performing the BAC Examination shall

a. Complete section 1 of the Attachment 3. '

b. Verify that the BAC Verifier is in the ON position.

c. If the BAC Verifier is not in the on position plug the BAC Verifier cord into 115 VAC power source equipped with a surge protector.

d. Turn Power ON/0TT Switch to ON.

e. Observe time (hours and minutes) displayed in '

upper right display and three dashes in lower left display.

l f. Allow unit to warm up for 10 to 20 minutes. (A longer warm-up is required if the BAC Verifier has been left in a cold environment).

g. Observe that green ready light is lit and the -

disappearance of the dashes on the lower left >

display, indicating the BAC Verifier is warmed-up and ready to run.

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DAVIS-SESSE ADMINISTRATIVE PROCEDURE

' I BAC Examinations 14 01 Is.DP-00100 l C2

h. Insert the disposable mouthpiece into the breath tube.

V

1. Pruss the RUN button.

j. Observe the BAC Verifier readying itself for the subject test. The following messages will display PUR, BLN and CAL.

k. observe the BLO message in the display.

1. Instruct the individual to take a breath and blow normally into the mouthpiece. If the test is not initiated within 2 minutes the BAC verifier will revert to the Ready To Run mode.

m. If the BAC reverts to the Ready To Run modo, GO l To step 6.5.4.1. l

n. Verify the Breath Alcohol Level displayed is l identical to the value printed on the BAC printout.

o. Set the timer for two minutes. C-2l

p. Wait at least 2 but no more than 10 minutes and take another breath test.

q. The test results shall be considered valid if the result of each test is within plus or minus 10 percent of the average of the two tests.

r. If the test results are not valid, the breath tests shall be repeated using a different evidentiary quality breath alcohol analysis device until test results are soccessful.

s. If the results of the first valid test indicate less than 0.01 percent blood alcohol concentration instruct the individual to return ,

to work.

t. If the results of the tests indicate a blood alcohol concentration of 0.04 percent or greater, and the individual requests a blood test, have the individual escorted to the Health Center for a blood test or if the Health Center is closed have the individual and a blood test Xit escorted to MaGruder Hospital in accordance with NG-IS-00004.

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• C sann DAVIS BESSE ADM6NISTRATIVE PROCEDURE PAGE REVl5loN PROCEoVRE NUMBER BAC Examinations 15 01 IS-DP-00100 C-1

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u. If the results of the tests are between, or include, 0.01 or 0.039 percent, Security shall coordinate the evaluation of whether the individual should be allowed to work in accordance with NG-IS-00004.

v. Remove the disposable mouthpiece.

w. Remove, sign, date, and attach the DAC printout to Attachment 3.

x. Complete section 2 of Attachment 3.

6.5.5 Upon completion of the BAC Examination the  !

individual performing the examination shall

a. Indicate in section 3, of Attachment 3 the breath alcohol level identified by the BAC Verifier.

b. Sign and date section 3, of Attachment 3.

c. Ensure that any witness (es) sign and date Section 3 of Attachment 3.

6.5.6 If BAC Verifier Test results are below specified limits a determination shall be made by the

j. Security Shift .eupervisor and test subject's l

supervisor if any further actions are required in accordance with NG-IS-00004.

6.5.7 The Security Shift Supervisor shall notify the .

General. Supervisor-Nuclear Security operations and Supervisor-Access control.

6.5.8 If no further actions are taken, the Security Shift Supervisor shall:

a. Forward the original Attachment 3 to Medical Services personnel at the Health Center with the BAC printout attached. ,

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DAVIS 8 ESSE ADMINISTPATNE PftOCEDURE 4 1&

BAC Examinations 16 01 13-DP-00100 ,i b.. Forward to the General Supervisor-Nuclear Security Operations a copy of Attachment 3 with a copy of the BAC printout attached.

6.5.9 If breath alcohol examination determines breath alcohol concentration to be 0.04 or greater, the Security shif t Supervisor shall deny access i authorization and notify a responsible individual to escort the tested individual from Toledo Edison property in accordancu with section 4 of Attachment 3. l 6.5.10 The Security Shif t Supervisor shall make a  !

reportability determination in accordance with IS-DP-00518. ._

6.5.11 The individual's encort shall sign section 4 of Attachment 3 to indicate acceptance of responsibility for the tested individual.  !

i NOTE _6.5.12 The Form shall either be hand delivered or placed in a sealed envelope marked " Confidential" i and forwardsd to the General Supervisor-Nuclear i Security Operations and the Health center.

6.5.12 The Security Shif t Supervisor shall forward all applicable Form to the General Supervisor-Nuclear Security operations and the Health Center.

6.5.13 The General Supervisor-Nuclear Security operations shall

a. Review all the applicable forms,

b. Sign all the applicable forms.

c. Forward the forms to the Supervisor-Access control for review and approval.

6.5.14 The Supervisor-Access Control shall evaluate the results in accordance vith NG-IS-00004 and make a determination as to Whether the tested individual is added to the Denied Access List in accordance with IS-AC-00017.

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.e. e O SESSE ADMINISTRATWE PROCEDURE PAGE mtvi$loN PmOct00mt NUMelm DAC Examinations 17 01 IS-DP-00100 7.0 RECORDS -

7.1 The following quality assurance records are completed by this procedure and shall be listed on the Nuclear Records List, captured, and submitted to Nuclear Records Management in accordance with NG-IM-00106.

None 7.2 The non-quality assurance records are completed by this procedure and may be captured and submitted to Nuclear Records Management in accordance with NG-IM-00106.

7.2.1 Justification for not performing a RAC Examination 7.2.2 Alcohol Related Investigation Report 7.2.3 Test Performance Report l

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e c ED Vl?l CAGE CEVISCN PROCEDURE NUMBER ,

DAVIS-SESSE ADMfNISTRATTVE PftOCEDU3E og Is.pp_oolog BAC Examina'tiont is ATTACMMENT 1; __

JUSTIFICATION _FOR NOT PERFORMING A BAC TYAMINATION

< bett graa.c,:,upm wiuoeuovu O ,

Cecogal Suoerviser-Muc}gs Q eguritt 09arstione SWutCT Justifiestion for not perf orniet EAC aussiascion On and ___ , I v .: t . af ermed by .

Date Ilme fres

_of a Titness for duty con related to alcohol.

Department Upn evaluation of the individual in questi I de d that a RAC enut ention was g required.

assons; I based this determinat

%"w cet Supervisor

• Acccas Control Attachment 1 Page 1 of 1 L

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I C__-_____-._-._._-.-__m._-______m_ _ _ _ _ _ _ _ _ _ . _ _ _ _____m_.._-________._______-__-.____.m__- _ _ _ _ _ . - - _ . _ . - - _ . _ _ _ _ _ _ . _ _ _ _ _ . - _ _ - - _____.__--________m___ --- ---

. t o M F1 DAV4 4 ESSE ADMINISTMATTVE PROCEDURE Pact mEvisioN emoctDunE Nuwara i

BAC Examinations 19 01 l

. IS-DP-00100 I

ATTACMMENT 2 A'uCPROL

.n. RELATED INVESTTGATION_ REPORT

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AL #re.

,-+ , RELATED INCIDENT REPORT SGNN 1. INDTVIDUAL. CONSENT I hereoy give enr consen to the Toteen Estaan Conveny, or doespeces egere, to persorm a Smam Akonal Deteccon Exemrisuori. I unoersians that fatae to ugn een connere torm, or e marna e the Exam we resut TED0% andM immeese AlaontW suspennen and la tunnected grouruBB ter tauchege and moosee cortel M encordance wth the Poecy.

g Test Doorsers Signemas One Weness signmane Date SECTION 2 INITIAL OBSEMVER Orgmal observer Correeny ; .

Poellen incews Dee/ Time Report Oncasse as pomnert insornmen i.e. oteervenen of n.

_ _ ._ A_ _

_m_;__ or go deseason of .

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I co 7 .URITY REPRESENTATIVE Test Suteocrs Name Company Social Securuy maseer il Badge maseer Approusnese Hosent . E' ,,te m.e Weign Test SutWecre Chtfung Desorgsph Test A% C2inervec PNyucal Conassen (Heir rinassest. Eyes genney, blocannot, estL)

Test Sutgees Moser Stdlle Test 9mi-Is Annues (Oc - a, Combalho, Seegerent, etc)

Test operaser signeurs Date Witness Sigrusure .

Dee Aewwwed try Dee General Svervisor - livelaar Security Operations (designee)

Rewwwed and Approved by Dale Supervisor - Accese Casaret (designee)

Wenemalmew General Supervisor - Wucisar Security Operations mee. enor ni we occa a mer es.

Attachment 2 Page 1 of 1 I

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to NN RAGE REvtsioN PectourE NUMnER DAVIS-8 ESSE ADMINISTRATIVE PftOCEDURE BAC Examinaf. ions 20 01 IS-DP-00100 ,

1 ATTACHMENT 3 TEST PERFORMANCE RE10RT l

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TEST PERFORMANCE REPORT SECTION 1 - PRE-TEST DATA Date of Last Calbravon Test Oste Date of Birm A:1al Secunty Num0er _

Name C

__ Beogo Number Male Femsa C Accress State 210 Coce _ , Instrument Senal Number City SECT 10N 2 CPERAllCNAL JHECXUST Observe suelect for twenty numtes prut te 26 N to provent W Intake of any matenst

() 1.

() 2. Pusn *RUN $UTTON* to Wttate testing stJasoce

() 3. Take cream sampne when BLO appears t t cseLAsy.

SECTION 3 TE md .

Descreut, of Test Events (Ls. mnge samt Mag ,

h e i

first test second T Jf/.101)

CONTISMAf0tt TEST First Test e eaststa (+/-10I) i W ACCese Ust. eIC.)

Acnon Taken (La Returned Test Operator Signature _ W Date Deze witness Signature Cheat if Se6ect Refused to S@ma to Test SECTION4 RELEACEFORM who has tested I am assuming responsMity for f acove acesotac6e 11mns on a areem Alcanot Detecten Devce. I anas ensure met the scove nam

1. cvacual is cmven to his/her resssence end esconed safeh innade, One synanne D**

ma*a W .

Report Revewed by -

casarsi Sueerrimrr - der.A.cf Security operations (dasignee)

Report Revewed and Acproved bY superviser - Ac. cess control (desisene)

Forwarc ongtnal to the Gemaral Supervisor - Nuclear Security operations send a copy te (n .noalth caen Ptaes copy in og ecok at test saa -

Attachment 3 Page 1 of 1 i

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e:nn DAGE CEVISION PROCEDUC'E NUMetR 6 AVIS 8 ESSE ADMINISTRATWE PROCEDURS BAC Examinations 21 01 IS-DP-00100

, COMMITMENTS Section Referarice Comment None 1

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