Form NRC Form 892 NRC Form 892 Annual Fatigue Reporting Form

NRC FORM 892
(MM-YYYY)

APPROVED BY OMB: NO. 3150-0146

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this collection request is 162 Hrs. This form is a voluntary means of reporting the information required
under 10 CFR 26.203(e). The information will be used by NRC to evaluate fatigue program performance related to work hour controls and waivers.
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 [email protected], 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 FFD Program Performance Data Reporting System
10 CFR Part 26, Subpart I - Managing Fatigue
Annual Fatigue Reporting Form for the EIE General Submission Portal
Select Facility

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Period of Report

Please Select

Today is:

Submission Update - check this box only if this is an update to a previous submission.
Did your facility issue any waivers in the
reporting period? (Yes / No)

Was this facility in an outage for any part of the
reporting period? (Yes / No)

Did any single site outage last more than 60
days in total? (Yes / No)

Did any of the first 60 days of an outage occur
during the reporting period? (Yes / No)

Did any of the outage days after day 60 occur
during the reporting period? (Yes / No)

Please Select

Please Select

Please Select

Please Select

Please Select

Summary of Waiver Issuance - 26.203(e)(1)(i-ii)
Number of Waivers Issued
Operating or on-site directing of
the operations of systems,as
described in 26.4(a)(1)

Work Hour Controls

Operating

Outage
(days 1-60)

Outage
(after day 60)

Performing health physics or
chemistry duties, as described in
26.4(a)(2)
Operating

Outage
(days 1-60)

Outage
(after day 60)

Performing duties of a fire brigade
member, as described in
26.4(a)(3) *
Operating

Outage
(days 1-60)

Outage
(after day 60)

Performing maintenance or
onsite direction of maintenance,
as described in 26.4(a)(4)
Operating

Outage
(days 1-60)

Outage
(after day 60)

Performing security duties, as
described in
26.4(a)(5)

Operating
Total

Outage
Total
(days 1-60)

Outage
Total
(after day 60)

Combined
Total

Outage
(days 1-60)

(Calculated)

(Calculated)

(Calculated)

(Calculated)

Operating

Outage
(after day 60)

Exceeded 16 work hrs in any 24 hr period
Daily Work
Hours
26.205(d)(1)

Exceeded 26 work hrs in any 48 hr period
Exceeded 72 work hrs in any 7 day period

Rest
Breaks
26.205(d)(2)

Less than 10 hr break b/t successive work
periods (or 8 hr break accommodating
scheduled transition b/t shifts)
Less than 34 hr break in any 9 day period
Average of less than 1 day off per week
for 8-hour shifts

Minimum
Days
Off
Per Shift
Cycle
26.205(d)(3)

Average of less than 2 days off per week
for 10-hour shifts
Average of less than 2.5 days off per week
for 12-hour shifts
Average of less than 2 days off per week
for 12-hour maintenance shifts
Average of less than 3 days off per week
for 12-hour security shifts

Minimum Days Off
for Outage
Activities (during first
60 days of outage)
26.205(d)(4) and
26.205(d)(5)
Alternate to Minimum
Days Off 26.205(d)(7)

Less than 3 days off per successive 15-day
period 26.205.(d)(4)
Less than 1 day off per 7-day period for
maintenance personnel 26.205.(d)(4)
Less than 4 days off per successive 15-day
period for security personnel 26.205.(d)(5)
54 hour maximum average
Total

* NOTE: For individuals performing fire brigade duties and other duties, please count them only under the fire brigade column. Do not double count these individuals.

Distribution of Waivers for Individuals in Each Category - 26.203(e)(1)(iii)

Summary of Corrective Action - 26.203(e)(2)

Number of Employees Issued Waivers
[Note: Even if no waivers were issued for a given column, please enter a value (e.g., 0) in at least one of the cells in the column]

Number of Waivers

Operating or on-site
directing of
the operations of
systems, as
described in 26.4(a)(1)

Performing health
physics or chemistry
duties as described in
26.4(a)(2)

(as applicable)

Analysis of Waiver Assessment Data: (Limit 10,000 characters)

Performing duties of a Performing maintenance
Performing security
fire brigade member as
or onsite directing of
duties as described in
described in
maintenance as
26.4(a)(5)
26.4(a)(3) *
described in 26.4(a)(4)

1
Analysis of Fatigue Assessment Data: (Limit 10,000 characters)
2
3
4
5

Conclusions: (Limit 10,000 characters)

6
7
8
Summary and Status of Corrective Actions: (Limit 10,000 characters)

9
10
11 - 20
More than 20

General Comments (optional) (Limit 10,000 characters)

Total Employees
Issued Waivers
(Calculated)

Most Waivers
Provided to a
Single Individual
* NOTE: For individuals performing fire brigade duties and other duties, please count them only under the fire brigade column. Do not double count these individuals.

Person(s) Responsible for Information Provided
Person 1 (required):

Person 2 (optional):

First Name

Last Name

Company Email Address

Position Title

First Name

Last Name

Position Title

Company Email Address

Final Step (Required) - NRC will consider this form authentic in accordance with 26.11 only when the “Validate & Lock” button has been selected and all errors (i.e., those highlighted in red) have
been corrected. The “Validate & Lock” button will change to “Locked” after the data validation process has been successfully completed and the form is ready for submission.

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Annual Fatigue Results Form (version 1.4.0 - Nov 5, 2012)