ML20063J247

Single Positive Test Form Collected on 12/16/2019

ML20063J247
Person / Time
Site:	Wolf Creek
Issue date:	02/18/2020
From:	Black P Wolf Creek
To:	Office of Nuclear Reactor Regulation, Office of Nuclear Security and Incident Response
Shared Package
ML20063J382	List: ML20063J228 ML20063J232 ML20063J234 ML20063J237 ML20063J240 ML20063J247 ML20063J252 ML20063J265 ML20063J273
References
D3-19, RA 20-0016
Download: ML20063J247 (1)

Text

• ' LJ S N RC ' FFD Program Performance Data Reporting System

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• N RC Forrn 800 S rr1 g le I' ,rt

• Test Form I I ,Ill.,,!',;*/, ,111/l/r1 J 11111,11n1

1) All field* required except thoH marhd 'optlonal' APPROVED BY 0 MB: CLEARANCE NO. 3150-4141 EXPIRES: 04/30/2021

2) EntrlH In some field* auto-populate Inform.ti on In other field* Estimated burden per response to comply with thia coHection requnt ii 30 minutn. Thia

3) Mouse ov.,. form fl.td* to view additional Information form Is a voluntary means of reporting fie Information ~eel under 10 CFR 26 .41 7(b)(2)

4) Use of Adobe Ruder I or later I* '*luired and 26.717 . The infonnation is required by NRC to obtain on an annual bull aite specilc fitness-for-duty (FFD) program performance data on chg and alcohol proe,alM from licensees and other entitiee. Send OOfflffllllS ragardng burden Ntlmate to the FOIA.,

Privacy and Information Collec1lon Brandl (TS-F53}, U.S . Nuclear Regulatory Commission, Washington DC 20555-0001, or by...,.. to lnfocollects Resource@NRC aov and to the Desk Officer, Office of lnforma11on and Regulatory Affairs. NEOB-1020, (3150-01 48), Office Unique Reference ID (l.lcenw Supplledl joa-19 I of Management and Budget, WnMngton DC 20503. If

• meana uaed to lmpOH information collection doea not fiaplay a ourrentty vaUd 0MB control number, the NRC may not conclJet or aponaor, and

• pal'IOl"I ii not required to reapond to, the information collection.

Date of Collect/on 1 12116/20 19 I (mm/d<Uyyyy) . .

Reason for Testing - 26.717(b)(5) P!.-Aa:au Tuting Reuon (apllanal) Please e ~ (oplionaQ 1~ j1nitia1Authortzatlon ..---------------,

Emp/oyff1ent Type -26.717(b)(3) Outage Worker (optional) 7 jcoullllCllll>"ff!IIIDI INo Labor Category - 26.717(b)(3)

ICOMPUTER SERVICES Is this a U-hour reportable event under 26.719(b)7 ~

Was this collect/on refused? - 28.717(b)(7) & 26.75 ~

Test Results - 28.717(b)(4)

Test Type(I) for Reoult(I) Reporllld- 26.717(b)(2) Drug Specimen Tested j0rug 0ny junne I Test Validity jva11c1 Was this collect/on observed? - 26.717(b)(7) & 28.75 ~

How many substances were confirmed positive far this individual?~'- - - - - -

UseNRC Initial Conflrmlllory Limit of Substance - 28.717(b)(2) & (b)(6)

Cutotll? Cutoff Cutoff Detection

!o piate: Codeine Subversion Attempt - Did this collection involve a subversion attempt?. 26.717(b)(7) and 26. 7S(b) ~j___N_o_ _~

Management Actions - 26.717(b)(8) & 28.75 Reaon for the Action Sanction Applied (NRC Mlrimurn or l.lcenlN Admlnlatraled) jNRC Minimum j14- Day Denllll Person(s) Responsible for lnformlltlon Provided Person 1 (required):

IPAMELA llaLACK J §ss SPECIALIST J PABLACKOVVCNoc.coM FlmN- ----r===------'~--~Poiltlon---Tiai-----

LiiiN- Company Email Address P.,.on 2 (opllonll):

I-A Fliil Nini II-

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LiitNiiii IISUPERVISOR ACCESS SCREENING PoilBon nBi I SOJONESQWCNOC.COM Company Ema,I Address Final Step (R* qulred)

• NRC w4N consider.,.. form authentic in accordance with 10 CFR 29.11 only when the -Validate & Lo<<button II clk:ked and al errcn (highlighted in red) have been corrected . The -Validate & Lock* button will change to *Locked* after the data validation proceu has been aucceaafully completed Indicating the form ts ready for aubmlnion.

Form Locked On:!Feb 18, 2020 at 10:09:13AM I I Save to Local PC 11 Pl1nt this Report I Single Positive TN! Form (version 1.8.0 - April 2018) NRC Form 890 (12/201 4)