ML21054A155
| ML21054A155 | |
| 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-2020-07 | |
| Download: ML21054A155 (1) | |
Text
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FFD Program Performance Data Reporting System
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A NRC Form 890 Single Pos1t1ve Test Fo1 m
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- 1) All fields required except those marlted 'optional'
- 2) Entries in some fields auto-populate lnfonnatlon In other fields
- 3) Mouse over form llelds to view additional information
- 4) Use of Adobe Reader 8 or later is required Submission Update Delete Submission Uni ue Reference ID Licensee Su ied PAL-2020-07 Facility
!Palisades [50-255]
APPROVED BY 0MB: CLEARANCE NO. 3150-G1'8 EXPIRES: 04/30/2021 Estimated burden per response to comply with this coUection 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 fs required by NRC to obtain on an annual basis site specific fitness-for-duty (FFO) program performance data on drug and elcohol programs from licensees and other entities. Send comments regarding burden estimate to the FOIA, Information Services Branch (T6*A10M), U.S. Nuclear Regulatory Commission, Weshlngton DC 20555-0001, or by e.rnail to JofocoUects 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.
Dale of Collect/on I 09/1712020 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 (safety-significant)
!Reinstatement (Between 31 and 365 days)
Outage Worker {optlonaQ?
Ives Is this a 24-hour reportable event under 26.719(b)?
Was this co/lecUon refused?* 26.717(b)(7) & 26.75 Test Results* 26.717(b)(4)
Test Type(s) for Result(s) Reported* 26.717(b)(2)
!Alcohol Only Substance
- 26.717(b)(2) & (b)(6)
!Alcohol Alcohol Specimen Tested
!Breath I
What 26.103 BAC level was exceeded?
I 0.04 or greater 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
!First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated) jucensee Administrated Specific Sanction Applied I1-Year Denial Person(s) Responsible for Information Provided Person 1 (required):
lscott I
!summers I
1%!JiFD Superviso, I
ssumme1@ente,gy.com
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Person 2 (optional):
First Name Last Name Position Title Company Email Address Fin al Step (Required)* NRC wiU 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 at 3:33:37 PM Single Positive Test Form (version 1.9.0-January 2020)
I Save to Local PC l I. Print ttils Report I NRC Form 890