ML21054A157
| ML21054A157 | |
| 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-2020-09 | |
| Download: ML21054A157 (1) | |
Text
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FFD Program Performance Data Reporting System NRC Form 890 Single Pos1t1ve Test Form 11,/-. /
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- 1) All fields required except those marl<ed 'optional'
- 2) Entries in some fields auto-populate lnformaUon In other fields
- 3) Mouse over form fields to view additional information
- 4) Use of Adobe Reader B or later Is required Submission Update Submission Uni ue Reference ID Licensee Su ied PAL-2020-09 Facility
!Palisades [50-255)
Reason for Testing - 26.717(b)(5)
!Random Employment Type - 26. 717(b)(3)
I Licensee Employee Labor Category - 26. 717(b)(3) jsecurity Please elaborate (optional)
Outage Worker (options/)?
INo Is this a 24-hour reportable event under 26.719(b)7 Was this collection refused?- 26.717(b)(7) & 26.75 Test Results - 26.717(b)(4)
APPROVED BY DMB: CLEARANCE NO. 3150-0146 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 basis she specific fitness-for-duty (FFO) 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 lnfocollects Resource@NRC QOY-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 currentty 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 11210312020 j (mm/dd/yyyy)
Test Type(s) for Result(s) Reported - 26.717(b)(2)
Drug Specimen Tested
!Drug Only junne I
Test Validity
!valid 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)
IMethamphetamine UseNRC Cutoffs?
Initial Confirmatory Limit of Cutoff Cutoff Detection 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
!First drug or alcohol positive Sanction Applied (NRC Minimum or Licensee Administrated)
I Licensee Administrated Specific Sanction Applied I3-Year Denial Person(s} Responsible for Information Provided Person 1 (required):
'~S-co_n __ ~~~----~l lsummers I
IAA/FFD Supervisor I
ssumme1@enlergy.com First Name
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Person 2 (optional):
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First Name Last Name Pos1bon Title Company Email Address Final Step (Required)
- NRC wiO 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.
Form Locl<ed On:!Feb 11, 2021 at 3:37:27 PM Single Positive Test Form (version 1.9.0 -January 2020)
I Save to Local PC 11 Print this Report J NRC Form 890 1i