ML21054A155

Single Positive Test Form Collected on 09/17/2020

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: ML21054A148 ML21054A149 ML21054A150 ML21054A151 ML21054A152 ML21054A153 ML21054A154 ML21054A155 ML21054A156 ML21054A157 ML21054A158
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