ML21054A157

Single Positive Test Form Collected on 12/03/2020

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: ML21054A148 ML21054A149 ML21054A150 ML21054A151 ML21054A152 ML21054A153 ML21054A154 ML21054A155 ML21054A156 ML21054A157 ML21054A158
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,/-. / I I, /j I /1,i I I I I , >

1) All fields required except those marl<ed 'optional' APPROVED BY DMB: CLEARANCE NO. 3150-0146 EXPIRES: 04/30/2021

2) Entries in some fields auto-populate lnformaUon In other fields Estimated burden per response to comply with this collection request is 30 minutes. This

3) Mouse over form fields to view additional information form is a voluntary means of reporting the information required under 10 CFR 26.417(b)(2)

4) Use of Adobe Reader B or later Is required 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, Submission Information Services Branch (T6-A10M), U.S. Nuclear Regulatory Commission, Washington Update Submission 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 Uni ue Reference ID Licensee Su ied Management and Budget, Washington DC 20503. If a means used to impose information PAL-2020-09 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.

Facility

!Palisades [50-255) Date of Collection (mm/dd/yyyy) 1 1210312020 j

Reason for Testing - 26.717(b)(5) Please elaborate (optional)

!Random I

Employment Type - 26. 717(b)(3) Outage Worker (options/)?

Licensee Employee INo Labor Category - 26. 717(b)(3) jsecurity 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)

I Test Type(s) for Result(s) Reported - 26.717(b)(2) Drug Specimen Tested

!Drug Only junne Test Validity

!valid Was this collection observed? - 26.717(b)(7) & 26.75 How many substances were confirmed positive for this individual?'~-----~

UseNRC Initial Confirmatory Limit of Substance - 26. 717(b)(2) & (b)(6)

Cutoffs? Cutoff Cutoff Detection IMethamphetamine 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 I

(NRC Minimum or Licensee Administrated)

Licensee Administrated Specific Sanction Applied I3-Year Denial Person(s} Responsible for Information Provided

~~~----~l I I Person 1 (required):

1i

'~S-co_n_ _ l summers IAA/FFD Supervisor ssumme1@enlergy.com

.___....-c=-~'~'-------,-=,-,=-,---~'~'

- First Name . ~-- -- ~c-a~st~N_,.

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onc--Ti"',"~e

'- - - ~- ----=c-om-pa_n_y-,E~m-a-,,il"A~d"d-re_s_s_ __

Person 2 (optional):

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 I Save to Local PC 11 Print this Report J Single Positive Test Form (version 1.9.0 -January 2020) NRC Form 890