ML18058A909

Single Positive Test Form, for Pre-Access, Collected on 03/13/17

ML18058A909
Person / Time
Site:	Palisades
Issue date:	05/23/2017
From:	Dotson B, Rabideau B Entergy Nuclear Operations
To:	Document Control Desk, Office of Nuclear Security and Incident Response
Shared Package
ML18058A902	List: ML18058A903 ML18058A905 ML18058A907 ML18058A908 ML18058A909 ML18058A910 ML18058A911 ML18058A912 ML18058A913 ML18058A914 ML18058A915 ML18058A916 ML18058A917 ML18058A918
References
2017-PAL-003
Download: ML18058A909 (1)

Text

FFD Program Performance Data Reporting System NRC Form 890, Single Positive Test Form (EIE General Submission Portal)

1) All fields required except those marked 'optional' APPROVED BY OMB: CLEARANCE NO. 3150-0146 EXPIRES: 11/30/2017

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

3) Mouse over form fields to view additional information form is a voluntary means of reporting the information required under 10 CFR 26.717. The

4) Use of Adobe Reader 8 or later is required 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, Privacy and Information Submission Delete Collection Branch (T5-F53), U.S. Nuclear Regulatory Commission, Washington DC Update Submission 20555-0001, or by e-mail to Infocollects.Resource@NRC.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-1020, (3150-0146), Office of Unique Reference ID (License Supplied)

Management and Budget, Washington DC 20503. If a means used to impose information 2017-PAL-003 collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

Select Facility Palisades [50-255] Date of Collection (mm/dd/yyyy) 03/13/2017 Reason for Testing - 26.717(b)(5) Pre-Access Testing Reason (optional) Please elaborate (optional)

Pre-Access Initial Authorization Employment Type - 26.717(b)(3) Outage Worker (optional)?

Contractor/Vendor No Labor Category - 26.717(b)(3) Please elaborate on the Labor Category selected Other Cooling Tower Replacement Is this a 24-hour reporting event? - 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) Drug Specimen Tested Drug Only Urine Test Validity Valid Was this collection observed? - 26.717(b)(7) & 26.75 No How many substances were confirmed positive for this individual? 1 Use NRC Initial Confirmatory Limit of Substance - 26.717(b)(2) & (b)(6)

Cutoffs? Cutoff Cutoff Detection Amphetamine Yes 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)

Licensee Administrated Specific Sanction Applied 3- Year Denial Person(s) Responsible for Information Provided Person 1 (required):

Brian Rabideau Supervisor Access Authorization/FFD brabide@entergy.com First Name Last Name Position Title Company Email Address Person 2 (optional):

Barb Dotson Licensing Specialist bdotson@entergy.com First Name Last Name Position Title Company Email Address 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: May 23, 2017 at 2:11:10 PM Save to Local PC Print this Report Single Positive Test Form (version 1.7.0 - December 2016) NRC Form 890 (12/2014)