ML21054A154

Single Positive Test Form Collected on 09/15/2020

ML21054A154
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-2020-06
Download: ML21054A154 (1)

Text

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NRC Form 890 Single Pos1t1ve Test Form I

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1) All fields required except those marlced 'optionar

2) Entries In some fields auto-populate lnfonnatlon In other fields

3) Mouse over fonn fields to view additional lnfonnation

4) Use of Adobe Reader 8 or later Is required Submission Update Submission Uni ue Reference ID Licensee Su ied PAL-2020-06 Fac/1/ty I

Palisades [50-255]

APPROVED BY 0MB: CLEARANCE NO. 3150-014' 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 basts site specific fitness-for-duty (FFD) program performance data on drug and alcohol programs from Ucensees and other entities. Send comments regarding burden estimate to the FOIA, Information Services Branch (T6-A.10M), U.S. Nuclear Regulatory Commission, Washington DC 20555-0001, or by e-mail to lofocollect:s Resource@NRC goy. 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 conb'ol number, the NRC may not conduct or sponsor, and a person Is not required to respond to, the information collection.

Date of Collect/on I 0911512020 I (mm/dd/yyyy)

Reason for Testing - 26.717(b)(5)

I Pre-Access Pr&-Access Testing Reason (optional)

Please elaborate (optional)

Employment Type - 26. 717(b)(3)

IContractorNendor Labor Catego,y - 26. 717(b)(3)

!Maintenance (safety-significant)

I Update Authorization Outage Worker (optional)?

Ives Is this a 24-hour reportable event under 26.719(b)?

Was this collect/on 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 I

Drug Only I Urine J

Test Validity lvalid Was this collection observed? - 26. 717(b)(7) & 26.75 How many substances were confirmed positive for this individual?'~-----~

Substance - 26. 717(b)(2) & (b)(6)

UseNRC Cutoffs?

Initial Confirmatory Limit of Cutoff Cutoff Detection Subversion Attempt-Did this collection involve a s~bversion attempt?- 26.717(b)(7) and 26,7;(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)

I Licensee Administrated Specific Sanction Applied 13--Year Denial Person(s) Responsible for Information Provided Person 1 (required):

I Ls_co_tt __ __,,,=-,,------- !summers I

IANFFD Sup0,v;5or_

I ssumme1@entergy.com First Name

'-----,-L"'as"'t-,N"accm"e,-----' '---~P"o-s~iti""on"','=T~iU_e ___ _, -----C-om-pa_n_y_E_m_a-il_A_dd_re_s_s __ _

Person 2 (optional):

~~~ll.______,~____,~~~-

F,rst Name Last Name Position Title Company Email Address Flna/Step(Requlred)

• 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 *Locked" after the data validation process has been successfully completed indicating the form is ready for submission.

I Fann Locked On:!Feb 11, 2021 at 3:32:33 PM Single Positive Test Fann (version 1.9.0 -January 2020)

I Save to Local PO I J Print this Report I NRC Fann 890