ML20057C817

Single Positive Test Form Collected on 02/04/2019

ML20057C817
Person / Time
Site:	Palisades
Issue date:	02/24/2020
From:	Summers S Entergy Nuclear Operations
To:	Document Control Desk, Office of Nuclear Security and Incident Response
Shared Package
ML20057C816	List: ML20057C817 ML20057C818 ML20057C819 ML20057C822 ML20057C824 ML20057C826 ML20057C828 ML20057C829
References
PAL-2019-01
Download: ML20057C817 (1)

Text

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FFD Program Performance Data Repor:1rig System

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NRC Forr11 890 S.r*g e Posit ve Test Fo*rn l'r11f1, 1111;: /',*,111/L*o1,d t!t,* / 1111(<1,,r 1 '/1,

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1) All fields requ/r~ except those mar*ed 'aptlonar

2) Entries In some fields auto-populate Information in other fields

3) Mouse over form fields to view addiflonal Information

4) Use of Adobe RHder 8 or later is required D

Submission Update D ~~~~~ssion Uni ue Reference ID Licensee Su lied PAL-2019-01 Facility jPafisades (50-255}

APPROVED BY 0MB: CLEARANCE NO. 3150.Q146 EXPIRES: 04130/2021 Eslimated burden per response to comply v.ilh lhtS eolection request is 30 rrinutes This form is a vok.lnta,y means offeportrlg the information requi"ed under 10 CFR 26.417{bX2J and 26 717 The information is,equlred by NRC to obtain on an annual basts site specific frtness-for-duty (FFD) program pelformance data on drug and a'cohot programs from licensees and other enlihs. Send comments regarding burden estimate to the FOIA, Privacy and Information Collection Bnmdi (T5-F53), U.S. Nucfear Regulatory Comnission.

Washi'lgton DC 20555-0001, or by e-mail to lnfo,:PAcc;ts BtH1,HU!@NBC QD.)I, 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 in-.,ose information collection does not display a cuuendy valid 0MB control number, the NRC may not conduct or sponsor, and a person is not requiled to respond to, the information collection.

Date of Col/action I 0210412019 J (mmlddlyyyy)

Reason for Testing - 26. 717(b)(5)

I Pre-Access Pre-Access Testing Reason (optional)

Please elaborate (optional)

Employment Type

• 26 717(b)(3) lcontractorNendor Labor Category

• 26.717(b)(3)

!Maintenance (general facility)

!Reinstatement (Between 31 and 365 days)

Outage Worker (options/)?

!No Is this a 24-hour reportable event under 26.719/b)? ~

Was this collection refused?

• 26.717(b)(7) & 26 75 ~

Test Resuns

• 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 Specimen Tested

!Breath IMlat 26 103 BAC level was exceeded?

\\o.04 Of greater Subversion Attempt

• Did this collection involve a subversion attempt?* 26.717(bX7) and 26.75(b) LI ___

N_o __

ManBQement Actions

• 26.717(b)(6) & 26 75 Reason for the Action

! First drug or alcohol pos~ive Sanction Applied (NRC Minimum Of Licensee Administrated)

!Licensee Administrated Specific Sanction Applied j1-Year Denial Person(s) Responsible for Information Provided Person 1 (required)

~ls_,o_*--~------~11 Summers I

AA/FFD Supe,-y~or First Name

~---~L-a-st~N-a_m_e ___ ~.._--~~o-,-rt,-on~Ti~tle ___ __,

Person 2 (optional};

saumme1@entergy.com Company Email Addrass

...._--=_____,!l.___-.,,..,..,.,~___,!I.___ ~~__, -~~~-

First Name Last Name Position Title Company Email Address Final Step (Requ;r*d)

• NRC will consider this form authentic in accordance with 10 CFR 26.11 onty 'Mlen the "Validate & Lock* button is clicked and all errors (highlighted in red} have been corrected. The "Validate & Lock* button will change to *Locked" after 1he data validation process has been successfully completed indicating the form is ready tor submission.

Form Locked on,!Feb 24, 2020 at 3*20 39 PM Single Positive Test Form (version 1.6.0. April 2018)

! Save to Local PC j j Print this Report i NRC Form 890 (1212014)