ML21054A150
| 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: |
| References | |
| PAL-2020-02 | |
| Download: ML21054A150 (1) | |
Text
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- 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
- 2) Entries In some fields auto-populate Information In other fields
- 3) Mouse over fonn fields to view additional information
- 4) Use of Adobe Reader 8 or later Is required Submission Update Delete Submission Uni ue Reference ID Licensee Su lied PAL-2020-02 APPROVED BY 0MB: CLEARANCE NO, 3150.0146 EXPIRES: 04/30/2021 Estimated burden per response to comply with this coRection request is 30 minutes. This form is a voluntary 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 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, Information Services Branch (T6*A10M), U.S. Nuclear Regulatory Commission, Washington 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 Management and Budget, Washington DC 20503. If a means used to impose information 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 I 0B/10/2020 I (mm/dd/yyyy)
Reason for Testing - 26. 717(b)(5)
I Pre-Access Pre-Access Testing Reason (optional)
Please elaborate (optional)
Employment Type - 26.717(b)(3)
IContractorNendor Labor Category - 26. 717(b)(3)
!Maintenance (general facility)
!Initial Authorization Outage Worker (optionaQ?
Ives 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 Result(s) Reported - 26. 717(b)(2)
Drug Specimen Tested jDrug Only
!Urine I
Test Validity
!valid Was this collection observed? - 26.717(b)(7) & 26. 75 How many substances were confirmed positive for this individual? L' -----~
Substance - 26. 717(b)(2) & (b)(6) lcocaine Use NRC Cutoffs?
Initial Confirmatory Limit of Cutoff Cutoff Oetedion 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 Person 1 (required):
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IAA/FFD Supe,viso, I
ssumme1@ente,gy.com First Name
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Person 2 (optional):
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First Name 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 Single Positive Test Fonn (version 1.9.0 -January 2020)
I Save to Local PC ! I Print this Report 7 NRC Fonn 890