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

Select 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)

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 3- Year Denial Save to Local PC Print this Report Unique Reference ID (License Supplied) 2017-PAL-003 Please elaborate on the Labor Category selected Cooling Tower Replacement

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 03/13/2017 Submission Update Person(s) Responsible for Information Provided Company Email Address brabide@entergy.com First Name Brian Position Title Supervisor Access Authorization/FFD Position Title Licensing Specialist First Name Barb Last Name Dotson Last Name Rabideau Company Email Address bdotson@entergy.com Person 1 (required):

Person 2 (optional):

Single Positive Test Form (version 1.7.0 - December 2016)

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 co mpleted indicating the form is ready for submission.

LockedForm Locked On:Ma y 23, 2017 at 2:11:10 PM Reason for the Action First drug or alcohol positiveDid 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: 11/30/2017 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 26.717. 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, Privacy and Information Collection Branch (T5-F53), U.S. Nuclear Regulatory Commission, Washington DC 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 Management and Budget, Washington DC 20503. If a means used to impose information 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.

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

NRC Form 890 (12/2014)

Is this a 24-hour reporting event? - 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 A mphetamine Yes Date of Collection (mm/dd/yyyy)

Outage Worker (optional)?