ML21054A150

Single Positive Test Form Collected on 08/10/2020

ML21054A150
Person / Time
Site:	Palisades
Issue date:	02/11/2021
From:	Summers S Entergy Nuclear Operations
To:	Office of Nuclear Security and Incident Response
Shared Package
ML21054A147	List: ML21054A148 ML21054A149 ML21054A150 ML21054A151 ML21054A152 ML21054A153 ML21054A154 ML21054A155 ML21054A156 ML21054A157 ML21054A158
References
PAL-2020-02
Download: ML21054A150 (1)

Text

'*, L! S N I{ C

• FFD Program Performance Data Reporting System 1

• ," -' NRC Form 890 Single Pos1t1ve Test Form

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1) All fields required except those matlced 'optionar APPROVED BY 0MB: CLEARANCE NO, 3150.0146 EXPIRES: 04/30/2021

2) Entries In some fields auto-populate Information In other fields Estimated burden per response to comply with this coRection request is 30 minutes. This

3) Mouse over fonn fields to view additional information form is a voluntary means of reporting the information required under 10 CFR 26.417(b)(2)

4) Use of Adobe Reader 8 or later Is required and 26.717. The information is required by NRC to obtain on an annual basis site specific fitness-for-duty (FFO) program performance data on drug and alcohol programs from 6censees and other entities. Send comments regarding burden estimate to the FOIA, Submission Delete Information Services Branch (T6*A10M), U.S. Nuclear Regulatory Commission, Washington Update Submission DC 20555-0001, or by e-mail to lnfoco!lects Resource@NRC gqy. and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-1020, (3150--0146), Office of Uni ue Reference ID Licensee Su lied Management and Budget, Washington DC 20503. If a means used to impose information PAL-2020-02 collection does not display a currentty valid 0MB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

Date of Collectfon (mm/dd/yyyy)

I 0B/10/2020 I Reason for Testing - 26. 717(b)(5) Pre-Access Testing Reason (optional) Please elaborate (optional)

I Pre-Access !Initial Authorization Employment Type - 26.717(b)(3) Outage Worker (optionaQ?

IContractorNendor Ives Labor Category - 26. 717(b)(3)

!Maintenance (general facility)

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)

I Test Type(s) for Result(s) Reported - 26. 717(b)(2) Drug Specimen Tested jDrug Only !Urine Test Validity

!valid Was this collection observed? - 26.717(b)(7) & 26.75 How many substances were confirmed positive for this individual? L'- - - - - ~

Use NRC Initial Confirmatory Limit of Substance - 26. 717(b)(2) & (b)(6)

Cutoffs? Cutoff Cutoff Oetedion lcocaine Subversion Attempt- Did this collection invol~e a subversion attempt?- 26.717(b)(7) an~ 26.75(b) LI_ _ _ N_o_ __,

Management Actions - 26.717(b)(8) &26.75 Reason for the Action

!First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated) lucensee Administrated Specific Sanction Applied 13--Year Denial Person(s) Responsible for Information Provided IIAA/FFD Person 1 (required):

ILs_co_tt_ _ -=,...,..,.,.,...----~l First Name lsummers

~----,.L-,; ij.:'.!l;<

Supe,viso, I ssumme1@ente,gy.com

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Person 2 (optional):

First Name

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Last Name Pos1t1on Title Company Email Address Final Step (Required) - NRC will consfder this form authentic in accordance with 10 CFR 26.11 only when the "\lalidate & Lock* button is clicked and all errors (highlighted in red) have been corrected. The "Validate & Lock* button will change to *Locked" after the data validation process has been successfully completed indicating the form is ready for submission.

I Fonn Locked on,!Feb 11, 2021 at3:27:11 PM ISave to Local PC !I Print this Report 7 Single Positive Test Fonn (version 1.9.0 -January 2020) NRC Fonn 890