ML21054A152
| ML21054A152 | |
| 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-2020-04 | |
| Download: ML21054A152 (1) | |
Text
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- FFD Program Performance Data Reporting System
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NRC Form 890 Single Pos1t1ve Test Fo1m C
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- 1) All fields required except those marft.ed '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-2020-04 Facility I
Palisades [50-255]
APPROVED BY 0MB: CLEARANCE NO. 3150-0146 EXPIRES: 04/30/2021 Estimated burden per response to comply with this coUection request Is 30 minutes. This form is a votuntary means of reporting the information required under 1 0 CFR 26.417(b)(2) and 26.717. The Information is required by NRC to obtaJn on an annual basis site specific fitness~for-duty (FFD) 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-A10M), U.S. Nuclear Regulatory Commission, Washington DC 20555-0001, or by e-mail to lnfocoOects Resource@NRC poy. 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 currently 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 Collection I 0812412020 I (mm/dd/yyyy)
Reason for Testing - 26.717(b)(5)
I Pre-Access Pre-Access Testing Reason (optional)
Please elaborate (optional)
I Reinstatement (Between 31 and 365 days)
Employment Type - 26. 717(b)(3) jcontractorNendor Labor Category - 26. 717(b)(3)
!Maintenance (general facility)
Outage Worker (optlonaQ?
jves Is this a 24-hour repottable 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 junne I
Test Validity lvalid Was this collect/on observed? - 26.717(b)(7) & 26.75 How many substances were confinned positive for this individual? I~-----~
Substance - 26.717(b)(2) & (b)(6)
I Marijuana UseNRC Cutoffs?
Initial Confirmatory Limit of Cutoff Cutoff Detedion Subversion Attempt - Did this collection involve a subversion attempt?-26.717(b)(7) and 26.75(b) ~I ___
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)
!Licensee Administrated Specific Sanction Applied j3-Year Denial Person(s) Responsible for Information Provided Person 1 (required):
~Is_*_**--=------~' ~ls_u_m_m_*r_*_~~~----~I IANFFD Supervisor I
ssumm~
ntergy.com
"'iirst Name Last Name
'---~P~o-s~iti-on~T,~-u-e ___ _,
"ircompany Email Address Person 2 (optional):
First Name Last Name Position Title Company Email Address Final Step (Required)* NRC 'Nill 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 'Nill change to *Lockedw after the data validation process has been successfully completed indicating the form Is ready for submission.
I Form Locked On:!Feb 11. 2021 at 3:30:42 PM Single Positive Test Form (version 1.9.0-January 2020)
I Save to Local PC ! I Pri(lt this Re'/iort I NRC Form 890