ML21054A153

Single Positive Test Form Collected on 08/30/2020

ML21054A153
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: ML21054A148 ML21054A149 ML21054A150 ML21054A151 ML21054A152 ML21054A153 ML21054A154 ML21054A155 ML21054A156 ML21054A157 ML21054A158
References
PAL-2020-05
Download: ML21054A153 (1)

Text

,. [ ' S N RC

• FFD Program Performance Data Reporting System

).

A NRC Form 890 Single Pos1t1ve Test Form 111, I

/ 1, 11/1 11!1, I 1/\\

C, (

1) All netds required except those marked 'optionar

2) Entries in some fields auto-populate Information In other fields

3) Mouse over form fields to view additional infonnation

4) Use of Adobe Reader 8 or later Is required Submission Update Submission Uni ue Reference ID Licensee Su ied PAL-2020-05 Faclllty I

Palisades [50-255]

Reason for Testing - 26.717(b)(5)

!Follow-up Employmerrt Type - 26.717(b)(3) lcontractorNendor Labor Category - 26. 717(b)(3)

Follow-up Testing Reason (optional) jPnor 10 CFR Part 26 positive result Outage Worker (optional}?

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) jAlcohol Only APPROVED BY 0MB: CLEARANCE NO.31-146 EXPIRES: 04/30/2021 Estimated burden per response to comply with this coDection 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 Hcensees and other entities. Send comments regarding burden estimate to lhe FOIA, Information Services Branch (T&-A 1 OM), U.S. Nuclear Regulatory Commission, Washington DC 20555-0001, or by e-mail to lnfocoliects Resource@NRC AOY-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, lhe NRC may not conduct or sponsor, and a person is not required to respond to, lhe Information collection.

Date of Collect/on I 0813012020 I (mm/dd/yyyy)

Substance-26.717(b)(2) & (b)(6)

!Alcohol Alcohol Specimen Tested

!Breath What 26.103 BAC level was exceeded?

jo.02 and in work status at least 2 hrs Subversion Attempt-Did this collection involve a subversion attempt?- 26.717(b)(7) and 26.75(b) '~--N_o __

Management Actions - 26. 717(b)(8) & 26. 75 Reason for the Action

!second drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated) j Licensee Administrated Specific Sanction Applied

'Permanent Denial Person(s) Responsible for Information Provided Person 1 (required):

lscott I

!summers First Name Last Name lf Person 2 (optional):

II First Name Last Name I

IANFFD Supervisor I

ssumme1@entergy.com Position Tide Company Email Address II 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 dicked 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 Form Locked On:!Feb 11, 2021 at3:31:44 PM Single Positive Test Form (version 1.9.0 - January 2020)

I Save to Local PO ! I Print this Report I NRC Form 890