ML21054A151
| ML21054A151 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 02/11/2021 |
| From: | Summers S Entergy Nuclear Operations |
| To: | Document Control Desk, Office of Nuclear Security and Incident Response |
| Shared Package | |
| ML21054A147 | List: |
| References | |
| PAL-2020-03 | |
| Download: ML21054A151 (1) | |
Text
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FFD Program Performance Data Reporting System
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NRC Form 890 Single Pos1t1ve Test Fo1m I
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- 1) All fields required except those marlfed 'optional'
- 2) Entries in some fields auto-populate lnfonnation In other fields
- 3) Mouse over fonn fields to view additional infonnatlon
- 4) Use of Adobe Reader 8 or later Is required Submission Update Submission Uni ue Reference ID Licensee Su lied PAL-2020-03 Facility
!Palisades [50-255]
APPROVED BY 0MB: CLEARANCE NO. 3150-0146 EXPIRES: 04/30/2021 Estimated burden per response to comply with this collection 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 licensees and other entities. Send comments regarding burden estimate to the FOIA, Information Services Branch (T6-A 1 OM), U.S. Nuclear Regulatory Commission, Washington DC 20555-0001, or by e-mail to lnfocollects 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 currenUy valid 0MB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
DateofCol/ectfon I 0811712020 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) lcontradorNendor jReinstatement (Between 31 and 365 days)
Outage Worker (optional)?
Ives Labor Catego,y - 26. 717(b)(3)
I Facility Support Is this a 24-hour reportable event under 26.719(b)?
Was this collectfon 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 junne I
Test Validity lva1id Was'~hls collection observed? - 26. 717(b)(7) & 26.75 How many substances were confirmed positive for this individual? Lj _____
Substance - 26. 717(b)(2) & (b)(6)
I Marijuana Use NRC Cutoffs?
Initial Confirmatory Limit of Cutoff Cutoff Detection Subversion Attempt-Did this collection involve a subversion attempt?- 26.717(b)(7) and 26.75(b) LI ___
N_o __
Management Actions - 26.717(b)(8) & 26.75 Reason for the Action I
First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated) jucensee Administrated Specific Sanction Applied 13-Year Denial Person(s) Responsible for Information Provided Person 1 (required):
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,.tt..__~------~l 1Ls_um_m_**-*-~~~----~' IAA/FFD Superv;sor J ll,'l.umme1@entergy.com
- Y First Name Last Name
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Person 2 (optional):
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First Name Last Name Position Title Company Email Address Final Step (Required)
- NRC will consider this form authentic in accordance with 10 CFR 26.11 only when the "Validate & Lock" button is clicked and all errors (highlighted in red) have been corrected. The "Validate & Lock" button will change to *tocked" after the data validation process has been successfully completed indicating the form is ready for submission.
I Fenn LockedOn:!Feb 11, 2021 at3:29:11 PM Single Positive Test Fenn (version 1.9.0 -January 2020)
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NRC Fenn 890