ML24052A302

Single Positive Test Form Collected on 10/18/2023

ML24052A302
Person / Time
Site:	Palisades
Issue date:	02/20/2024
From:	Hartmann J Holtec Palisades
To:	Document Control Desk, Office of Nuclear Security and Incident Response
References
PAL-2023-03
Download: ML24052A302 (1)

Text

,l U.S.NRC FFD Program Performance Data Reporting System

( 11l< 1-..1,tl,:\\ll< k irl.:.q.~u l 1t,n< 11 "'" NRC Form 890,Single Positive Test Form Protec fmK Peaple mu/ the ---I m*1ro1111w111 (submit using the NRC EIE General Submission portal)

1) All fields required except those marked 'optional' APPROVED BY OMB: CLEARANCE NO. 3150-0146 EXPIRES: 09/30/2024

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

3) Mouse over form fields to view additional information is a voluntary means of reporting the information required under 10 CFR 26.417(b)(2) and 26.717. The information is required by the NRC to obtain on an annual basis site specific

4) Use of Adobe Reader 8 or later is required 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 Submission Delete Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Update Submission 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 Unique Reference ID (Licensee Supplied) Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; PAL-2023-03 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.

Facility Palisades [50-255] Date of Collection 10/18/2023 (mm/dd/yyyy)

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

Random

Employment Type - 26.717(b)(3) Outage Worker (optional)?

Licensee Employee No

Labor Category - 26.717(b)(3)

Facility Support

Is this a 24-hour reportable event under 26.719(b)? No

Was this collection refused? - 26.717(b)(7) & 26.75 No

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

What 26.103 BAC level was exceeded?

0.04 or greater

Subversion Attempt - Did this collection involve a subversion attempt? - 26.717(b)(7) and 26.75(b) No

Management Actions - 26.717(b)(8) & 26.75 Reason for the Action First drug or alcohol positive

Sanction Applied (NRC Minimum or Licensee Administrated)

NRC Minimum

Specific Sanction Applied 14-Day Denial

Person(s) Responsible for Information Provided Person 1 (required):

Jean Hartmann Access Authorization Supervisor j.hartmann@holtec.com

__ First Name ___,l~I __ Last Name _______,~-~ Position Title L J Company Email Address

Person 2 (optional):

'--------------'-- 1 ___ First Name Last NamePosition TitleCompany Email Address____.J I

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 20, 2024 at 8:18:17 AM____ Save to Local PC Print this Report____.I I.___ ____.

Single Positive Test Form (version 1.11.0 - November 2022) NRC Form 890