ML24052A303

Single Positive Test Form Collected on 11/28/2023

ML24052A303
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-2023-04
Download: ML24052A303 (1)

Text

Facility Palisades [50-255]

Reason for Testing - 26.717(b)(5)

Pre-Access Pre-Access Testing Reason (optional)

Initial Authorization Please elaborate (optional)

Employment Type - 26.717(b)(3)

Contractor/Vendor Labor Category - 26.717(b)(3)

Facility Support 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 3-Year Denial Save to Local PC Print this Report Unique Reference ID (Licensee Supplied)

PAL-2023-04

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 11/28/2023 Submission Update Person(s) Responsible for Information Provided Company Email Address j.hartmann@holtec.com First Name Jean Position Title Access Authorization Supervisor Position Title First Name Last Name Last Name Hartmann Company Email Address Person 1 (required):

Person 2 (optional):

Single Positive Test Form (version 1.11.0 - November 2022)

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 8:17:15 AM 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)

Licensee Administrated 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 the 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 (submit using the NRC 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 Quantitation Marijuana Yes Date of Collection (mm/dd/yyyy)

Outage Worker (optional)?

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