Acrobat 9.0 PERFORMANCE PAGE Print Form Page of Work Package / Rev No.: Tech Procedure No.: SME Concurrence: RadCon: N/A Name Signature Date IH: N/A Name Signature Date Engineering: N/A Name Signature Date - SME: + Name Signature Date USQ Evaluation: Yes No Work potentially affecting a Hazard Category II or III Nuclear Facility? If yes, Categorical Exclusion, Screening, or Determination Number and signature by a USQ evaluator are required: USQ #: USQ Evaluator(s): Name Signature Date Signature Date Name Based on input from the walkdown team and my personal review, the detailed scope of work above is relevant to this work package, meets technical requirements under my cognizance, can be performed safely and the JHA controls are adequate. Name Signature Date Manager: Completion Review: Work as described above has been completed. Work Supervisor: Name Signature Date Record Date and Work Performed: (N/A if recorded on attached Work Package Status Logs)
PERFORMANCE PAGE Acrobat 9.0 Print Form Work Package / Tech Procedure No.: Rev No.: Page of SME Concurrence: RadCon: N/A Name Signature Date IH: N/A Name Signature Date Engineering: N/A Name Signature Date - SME: + Name Signature Date USQ Evaluation: Yes No Work potentially affecting a Hazard Category II or III Nuclear Facility? If yes, Categorical Exclusion, Screening, or Determination Number and signature by a USQ evaluator are required: USQ #: USQ Evaluator(s): Name Signature Date Name Signature Date Based on input from the walkdown team and my personal review, the detailed scope of work above is relevant to this work package, meets technical requirements under my cognizance, can be performed safely and the JHA controls are adequate. Manager: Name Signature Date Completion Review: Work as described above has been completed. Work Supervisor: Name Signature Date Record Date and Work Performed: (N/A if recorded on attached Work Package Status Logs)
EPC-FS-307_Performance_Page_DRAFT.docx