ML23051A023

Single Positive Test Form Collected on 03/15/2022

ML23051A023
Person / Time
Site:	Palisades
Issue date:	02/20/2023
From:	Summers S, Hartmann J Entergy Nuclear Operations, Holtec Decommissioning International
To:	Office of Nuclear Security and Incident Response, Document Control Desk
References
PAL-2022-04
Download: ML23051A023 (1)

Text

Facility Palisades [50-255]

Reason for Testing - 26.717(b)(5)

Pre-Access Pre-Access Testing Reason (optional)

Reinstatement (Between 31 and 365 days)

Please elaborate (optional)

Returning from Short Term Disability.

Employment Type - 26.717(b)(3)

Licensee Employee Labor Category - 26.717(b)(3)

Other Was this collection refused? - 26.717(b)(7) & 26.75 Test Results - 26.717(b)(4)

Test Validity Valid Test Type(s) for Result(s) Reported - 26.717(b)(2)

Drug Only Drug Specimen Tested Urine Was this collection observed? - 26.717(b)(7) & 26.75 Management Actions - 26.717(b)(8) & 26.75 Specific Sanction Applied 14-Day Denial Save to Local PC Print this Report Unique Reference ID (Licensee Supplied)

PAL-2022-04 Please elaborate on the Labor Category selected Document Control Administrative Assistant

1) All fields required except those marked 'optional'

2) Entries in some fields auto-populate information in other fields

3) Mouse over form fields to view additional information

4) Use of Adobe Reader 8 or later is required No No 03/15/2022 Submission Update Person(s) Responsible for Information Provided Company Email Address s.summers@holtec.com First Name Scott Position Title Access Authorization Supervisor Position Title Access Authorization Supervisor First Name Jean Last Name Hartmann Last Name Summers Company Email Address j.hartmann@holtec.com Person 1 (required):

Person 2 (optional):

Single Positive Test Form (version 1.10.0 - October 2021)

Final Step (Required) - 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.

Locked Form Locked On: Feb 16, 2023 at 3:11:35 PM Reason for the Action First drug or alcohol positive Did this collection involve a subversion attempt? - 26.717(b)(7) and 26.75(b)

No Subversion Attempt -

Sanction Applied (NRC Minimum or Licensee Administrated)

NRC Minimum Delete Submission FFD Program Performance Data Reporting System APPROVED BY OMB: CLEARANCE NO. 3150-0146 EXPIRES: 09/30/2024 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 site specific fitness-for-duty (FFD) program performance data on drug and alcohol programs from licensees and other entities. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e_mail to Infocollects.Resource@NRC.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0146), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail:

oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

NRC Form 890, Single Positive Test Form (EIE General Submission Portal)

NRC Form 890 Is this a 24-hour reportable event under 26.719(b)?

No No How many substances were confirmed positive for this individual?

1 Substance - 26.717(b)(2) & (b)(6)

Use NRC Cutoffs?

Initial Cutoff Confirmatory Cutoff Limit of Detection Marijuana Yes Date of Collection (mm/dd/yyyy)

Outage Worker (optional)?

'1'l U.S.NR C l 111tul S t llt"~ Sudt"tr Rt"f;ULttury Comm1.. ~1on Protectmg People mu/ the r11t'/ro111ue111 JI 17 --c--

~ --1~1 - - ~ ~ - - - - - - - - 1

~--~~--~l~I ----------1

___.I.__

I

_____.