November 29, 2006

Susan M. Allan, M.D., J.D.

Public Health Division Director

Oregon Department of Human Services

800 NE Oregon Street, Suite 930

Portland, OR 97232

Dear Dr. Allan:

On November 7, 2006, the Management Review Board (MRB) met to consider the proposed

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Oregon

Agreement State Program. The MRB found the Oregon program adequate, but needs

improvement, and compatible with the U.S. Nuclear Regulatory Commission’s (NRC’s)

program. Specific note should be made of Recommendation 3, which was a previous

recommendation and states, in part, “...that the Section discontinue the routine use of advance

authorizations pending development of a procedure and basis for issuing the authorizations.” 

Because of the significance of the findings, the MRB determined that the Oregon program

should undergo a period of heightened oversight. Heightened oversight is an increased

monitoring process used by NRC to follow the progress of improvement needed in an

Agreement State program. It involves preparation of a program improvement plan, bimonthly

conference calls, and submission of status reports prior to each call with the appropriate

Oregon and NRC staffs.

Section 5.0, page 13, of the enclosed Final Report presents the review team’s

recommendations for the State of Oregon. We request that you prepare and submit a program

improvement plan as part of your response to the review team’s recommendations. I ask that

you have your staff discuss the required elements of this plan with Ms. Janet Schlueter,

Director, Division of Materials Safety and State Agreements, Office of Federal and State

Materials and Environmental Management Programs, to ensure that the “get-well” path and

measures of success are clearly identified. The plan should be submitted within 30 days of

receipt of this letter. Upon review of your program improvement plan, NRC staff will schedule

the first conference call. The initial conference call should be scheduled and conducted no later

than February 7, 2007. Based on the results of the current IMPEP review, a followup review will

be scheduled approximately one year from the date of the August 2006 IMPEP review. The

followup review will cover the State’s actions in response to the recommendations in the

enclosed final report.
S. Allan -2-

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. I

also wish to acknowledge your continued support for the Radiation Control Program. I look

forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Waste,

 Research, State, Tribal, and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

Integrated Materials Performance Evaluation

Program Review of Oregon Agreement State Program

cc: T. Lindsey, Manager

Oregon Radiation Protection 

 Services Section

Ken Niles, State Liaison Officer

Oregon Department of Energy

Craig Jones, Utah

Organization of Agreement

 States Liaison to the MRB
S. Allan -3-

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. I

also wish to acknowledge your continued support for the Radiation Control Program. I look

forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Waste,

 Research, State, Tribal, and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

Integrated Materials Performance Evaluation

Program Review of Oregon Agreement State Program

cc: T. Lindsey, Manager

Oregon Radiation Protection 

 Services Section

Ken Niles, State Liaison Officer

Oregon Department of Energy

Craig Jones, Utah

Organization of Agreement

 States Liaison to the MRB

Distribution DCD (SP01) PDR (YEST)

DIR RF

JLynch, RIII

LMcLean, RIV SUNSI Review Complete

AJones, FSME/DILR : Publicly Available G Non-Publicly Available

RHays, RIII : Non-Sensitive G Sensitive

MLight, OH

CMiller, FSME Chairman Klein

KCyr, OGC Commissioner McGaffigan

WRautzen, FSME/MSSA Commissioner Merrifield

FCameron, OGC Commissioner Jaczko

AKock, OEDO Commissioner Lyons

TCombs, OCA (2 copies)

 To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure 

"E" = Copy with attachment/enclosure "N" = No copy

OFFICE DMSSA/SAIS DMSSA/SAIS:BC FSME/DMSSA:DD FSME/DMSSA:D DEDMRT

NAME ATMcCraw:kk:gd PARathbun SWMoore JRSchlueter MJVirgilio

DATE 11/21/06 11/21/06 11/21/06 11/22/06 11/29/06

ML063360005 Pkg. OFFICIAL RECORD COPY
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF OREGON AGREEMENT STATE PROGRAM

August 21-24, 2006

FINAL REPORT

U.S. Nuclear Regulatory Commission

ENCLOSURE
Oregon Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Oregon Agreement State Program. The

review was conducted during the period of August 21-24, 2006, by a review team comprised of

technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and the State of

Ohio. Team members are identified in Appendix A. The review was conducted in accordance

with the “Implementation of the Integrated Materials Performance Evaluation Program and

Rescission of Final General Statement of Policy,” published in the Federal Register on 

October 16, 1997, and the February 26, 2004, NRC Management Directive 5.6, "Integrated

Materials Performance Evaluation Program (IMPEP)." Preliminary results of the review, which

covered the period of August 31, 2002, to August 24, 2006, were discussed with Oregon

management on the last day of the review.

A draft of this report was issued to Oregon for factual comment on September 21, 2006. 

Oregon responded to the findings and conclusions of the review by letter dated October 19,

2006, from Terry Lindsey, Manager, Radiation Protection Services Section (the Section). The

Management Review Board (MRB) met on November 7, 2006, to consider the proposed final

report. The MRB found the Oregon Agreement State Program adequate, but needs

improvement, and compatible with NRC's program. Because of the significance of the findings,

the MRB determined that the State would benefit from a period of Heightened Oversight.

The Oregon Agreement State Program is administered by the Section. The Section is part of

the Office of Environmental Public Health (the Office) in the Public Health Division (the

Division). The Division is located within the Department of Human Services (the Department). 

Organization charts for the Division, the Office and the Section are included as Appendix B. At

the time of the review, the Section regulated approximately 334 specific licenses and 84

general licenses, including naturally occurring or accelerator-produced radioactive material

(NARM). The review focused on the radioactive materials program as it is carried out under the

Section 274b. (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC

and the State of Oregon.

In preparation for the review, a questionnaire addressing the common and non-common

performance indicators was sent to the Section on June 26, 2006. The Section provided its

response to the questionnaire on August 10, 2006. A copy of the questionnaire response may

be found in the NRC’s Agencywide Documents Access and Management System (ADAMS)

using the Accession Number ML062480463.

The review team's general approach for conduct of this review consisted of: (1) examination of

the Section’s response to the questionnaire; (2) review of applicable Oregon statutes and

regulations; (3) analysis of quantitative information from the Section’s licensing and inspection

database; (4) technical evaluation of licensing and inspection actions; (5) field accompaniments

of two Oregon inspectors; and (6) interviews with staff and management to answer questions or

clarify issues. The review team evaluated the information gathered against the established

criteria for each common and applicable non-common performance indicator and made a

preliminary assessment of the Agreement State program’s performance.

Section 2 of this report discusses the State’s actions in response to recommendations made

following the previous IMPEP review. Results of the current review for the IMPEP common

performance indicators are presented in Section 3. Section 4 discusses results of the
Oregon Final Report Page 2

applicable non-common performance indicators, and Section 5 summarizes the review team's

findings and recommendations. The recommendations made by the review team are

comments that relate directly to program performance by the State. A response is requested

from the State to all recommendations in the final report.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on August 30, 2002, four

recommendations were made and the results were transmitted to Grant K. Higginson, M.D.,

Acting Department Administrator, on December 11, 2002. The review team’s evaluation of the

current status of the recommendations is as follows:

1. The review team recommends that the Section complete development of the program

management software and continue to maintain capability in this area which is vital to

successful performance of the program. (Section 3.3 of the 2002 report)

Current Status: The radioactive materials program database is approximately 70

percent completed. Although the Section lost its dedicated programmer in 2002 as a 

result of the newly reorganized and centralized Information Technology/Information

Management Office, the Section’s inspection and licensing database did not reveal any

overdue activities or workload backlogs. The review team observed that the Section

had expended considerable effort to make up the staffing shortfall. The review team

determined that the lack of a dedicated Information Technology programmer has not

negatively impacted the Section’s ability to successfully manage the program

electronically nor compromised its ability to protect public health and safety. This

recommendation is closed.

2. The review team recommends that the Section discontinue the routine use of advance

authorizations pending development of a procedure and basis for issuing the

authorizations. Once developed, the Section should have the practice of issuing

advance authorizations and the procedure reviewed by counsel and its Radiation

Advisory Committee. The review should include the form and content of the

authorizations, the legal basis for issuing notifications prior to issuance of a license, as

well as a determination of the potential impact on health and safety issues. In addition,

the review should determine the State’s potential liability and the compatibility of the

practice with established State and Federal regulations, including requirements imposed

on distributors of devices containing radioactive material. (Section 3.4 of the 2002

report)

Current Status: At the time of the review, the Section continued to issue advance

authorizations as noted in Section 3.4. The Section had not developed a procedure and

basis for issuing the authorizations and subsequently had not had legal or Radiation

Advisory Committee review. This recommendation remains open.

3. The review team recommends that Oregon report events requiring greater than 24-hour

notification to the NRC on a monthly basis; ensure that all reports through August 2002

have been entered into Nuclear Material Events Database (NMED); correct missing data

on all NMED reports submitted; update and close out previously reported incidents; and

resolve data transmittal problems. (Section 3.5 of the 2002 report)
Oregon Final Report Page 3

Current Status: Following the 2002 IMPEP review, the Section made the required

incident reports and corrections to the NRC and to NMED. During this review period,

however, the Section had additional failures to report incidents to the NRC Headquarters

Operations Center and to NMED. Since the previous recommendation was specific to 

incidents from the last review period, the team elected to close that recommendation

and issue a new recommendation based on the IMPEP review findings outlined in

Section 3.5. This recommendation is closed.

4. The MRB recommends that the NRC review, in coordination with the States, the issues

of data sharing, closing and completing NMED reports, and process used to provide

periodic feedback to States on the status of their submittals.

Current Status: This issue was covered during the June 21, 2005 Periodic Meeting. 

The NRC representatives discussed with State personnel how NRC shares national

event data with the Agreement States. A copy of the Office of State and Tribal

Programs (STP) Event Reporting Self-Assessment Report, an NMED Quarterly Report,

and an NMED Newsletter that provided guidance on the distinction between “closed”

and “complete” event report records, were provided to the State. This recommendation

is closed.

3.0 COMMON PERFORMANCE INDICATORS

IMPEP identifies five common performance indicators to be used in reviewing both NRC

Regional and Agreement State programs. These indicators are: (1) Technical Staffing and

Training, (2) Status of Materials Inspection Program, (3) Technical Quality of Inspections,

(4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation

Activities.

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Section’s staffing level and staff

turnover, as well as the technical qualifications and training histories of the staff. To evaluate

these issues, the review team examined the Section’s questionnaire response relative to this

indicator, interviewed Section management and staff, reviewed job descriptions and training

records, and considered any possible workload backlogs.

The Section is headed by the Section Manager. The Section has two programs: the

Radioactive Materials Licensing, Emergency Preparedness, and Tanning Program and the

Electronic Products Program. Each program is headed by a Program Manager. An Acting

Program Manager is currently managing the Radioactive Materials Licensing, Emergency

Preparedness, and Tanning Program. The former Program Manager for that program is retiring

in January 2007. For the remainder of his employment with the Section, he has been assigned

full-time responsibility and oversight for rulemaking actions.

The Section is responsible for the routine licensing and inspection of 334 specific radioactive

materials licenses and 84 general licenses. The Section has approximately 5.25 full-time

equivalents (FTE) assigned to perform the technical aspects of the radioactive materials

program.
Oregon Final Report Page 4

The qualifications of the staff were determined from the questionnaire, training records, and

interviews of personnel. The staff members are well qualified through both education and

experience. All staff members have at least a Bachelor’s degree in the sciences, or equivalent

training and experience. The Section hired a medical physicist in June 2006. The special

expertise of the medical physicist should be very advantageous to the Section, both for

evaluation of incidents and for training of personnel.

The Section has a comprehensive and effective training plan for staff and new employees,

modeled after NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in

the Nuclear Materials Safety and Safeguards Program Area.” The Section uses a combination

of formal training and on-the-job experience to qualify the inspectors and license reviewers.

Although, the staff was technically qualified to perform inspection and licensing activities, the

review team observed through interviews, that critical knowledge of the reporting requirements

for radioactive material events to the NRC and NMED was in need of improvement. The review

team believes that this lack of knowledge was the root cause of the Section’s failure to report

events timely during this review period, as discussed in Section 3.5 of this report. The Section

Manager indicated that a training session would be provided to the staff.

The Section is currently restructuring and undergoing a comprehensive program review and

reorganization. The reorganization will be executed and accomplished in a two-phased

transition which has, thus far, included a change from a three-program management

organization to the current two-program management organization. In May 2006, during the

first phase of the reorganization, a Lead Worker was assigned to the Radioactive Materials

Licensing, Emergency Preparedness, and Tanning Program to handle increased

responsibilities for program oversight. In the second phase of the plan, planned for the first half

of 2007, program functions will be divided by modality. All inspection functions will be located

in the Field Operations Unit and all licensing and administration functions will be in the

Licensing and Administration Unit. The Field Operations Unit will include all inspection and

technical staff from both Programs. The Licensing and Administration Unit will include the

Licensing Assistant and all administrative staff. An extensive cross-training program will be

implemented for staff in both Units with new assignments for technical staff to assist with

radioactive materials inspection, emergency preparedness planning, and incident response

duties. The Department considers the reorganization to be an improvement in program

efficiency and functional assignments resulting in better response to incident investigations,

licensing activities and anticipated increases in portable and fixed gauge facilities.

In August 2006, the Section posted employment announcements for two vacant positions. The

two vacant positions were filled and are currently assigned to the Electronic Products Program. 

One position was been filled by a board certified nuclear medicine physician and the other by

an experienced inspector with a Bachelor’s degree in chemistry. At the completion of the

Section reorganization, the positions will be assigned to the Field Operations Unit and will be

the first two positions to undergo full cross-training for inspections in tanning, x-ray and

radioactive materials activities.

The review team noted that the Section had stable funding during the review period. The

Section collects 100 percent of its budget from fees, which go into a dedicated fund. This

radiation control fee fund became effective in July 2005 and has allowed funding of training and

grade increases for current staff. In 2006, the Department requested a radiation program fee
Oregon Final Report Page 5

increase. The requested fee increase was approved by the Radiation Advisory Committee and

Department of Administrative Services and is now subject to legislative review. The

Department is expecting the fee change to be approved by July 2007.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon’s performance with respect to the indicator, Technical Staffing and Training, was

satisfactory.

3.2 Status of Materials Inspection Program

The review team focused on five factors in reviewing this indicator: inspection frequency;

overdue inspections of Priority 1, 2, and 3 licensees; initial inspection of new licenses; timely

dispatch of inspection findings to licensees; and the performance of reciprocity inspections. 

The review team’s evaluation is based on the Section’s response to the questionnaire relative to

this indicator, data gathered from the Section’s licensing and inspection database, the

examination of completed inspection casework, and interviews with managers and staff.

The review team’s evaluation of the Section’s inspection priorities verified that several

inspection frequencies for various license types are more frequent than similar license types

listed in NRC’s IMC 2800. An example of Oregon’s increased inspection frequencies is medical

broad scope licenses, which the State inspects annually, compared to NRC’s two-year

frequency. Two license categories, source material and special nuclear material possession,

had inspection frequencies of three years as opposed to the two-year frequency in IMC 2800. 

According to the Section Manager, these two categories are not currently used and will be

changed to conform with the NRC’s frequency.

The Section tracks all inspection activities in a computer database. The review team observed

that the database can be queried by program managers and staff members to determine

inspection status for any licensed facility. Since the loss of its dedicated computer programmer

in 2002, the Section has lost flexibility to rapidly develop useful information technology reporting

tools, but has adjusted to the centralization of the information technology functions in the

Division.

The Section Manager indicated that no licenses were currently overdue for inspection using

Oregon’s inspection frequencies, which as stated earlier, require more frequent inspections

than NRC standards. Of the 550 inspections completed during the review period, only one was

completed overdue. All 17 initial inspections required during the review period were completed

within one year of license issuance.

The timeliness of the issuance of inspection findings was determined by the review team’s

evaluation of inspection casework. The Section typically issues an Oregon Form 591, similar to

NRC’s Form 591M, to a licensee at the conclusion of an inspection; therefore, the Section

exceeds the timeliness criteria for this indicator. The Section requires a written response to any

violations identified on an Oregon Form 591. Licensee compliance with that response

requirement, as well as inspection report handling and tracking is discussed in Section 3.3

below.

Reciprocity was granted to 11 licensees in 2002, 20 licensees in 2003, 15 licensees in 2004, 23

licensees in 2005 and 20 licensees thus far in 2006. The Section’s reciprocity inspection goals
Oregon Final Report Page 6

are equivalent to the requirements in IMC 1220 (20 percent of candidate licensees). The

review team determined that the Section inspected 72 percent of candidate licensees during the

review period, which is significantly greater than the IMC 1220 reciprocity inspection

requirements.

The review team examined the list of licensees that the Section had determined met the criteria

for the increased controls per COMSECY-05-0028. The review team determined that the

Section had correctly identified the Oregon licensees that require increased controls based on

this criteria. The Section has prioritized its licensees and has begun inspections of these

licensees in accordance with the increased controls requirements.

The team also reviewed the Section's work on general licensees. The Section currently has 84

registered general licensees. Each year, the Section requires a confirmatory inventory and a

fee from registrants. General licensees are inspected at 5-year intervals. Nationally, Oregon

has joined the Organization of Agreement States in petitioning the NRC for rulemaking

concerning general licenses (and specifically, compatibility of regulations). Presently,

compatibility with the NRC's general license rule (10 CFR 31.5) is held in abeyance, pending

Commission action on the petition. In the interest of public health and safety, Oregon requires

several companies using some higher quantity generally-licensed radiation sources to obtain

specific licenses for possession of the sources in the State.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon’s performance with respect to the indicator, Status of Materials Inspection

Program, was satisfactory.

3.3 Technical Quality of Inspections

The review team evaluated the inspection reports, enforcement documentation, and inspection

field notes, and interviewed inspectors and supervisory staff for 15 radioactive materials

inspections conducted during the review period. The casework reviews included inspections

conducted by two radioactive materials inspectors and covered various license types including: 

industrial radiography, academic and industrial broad scopes, high dose-rate remote

afterloaders, nuclear medicine, radiopharmaceutical therapy, brachytherapy, nuclear

pharmacies, and veterinary imaging. The review team evaluated documentation for one

increased controls inspection. Appendix C lists the inspection casework reviewed, with casespecific comments, as well as the results of the review team’s inspector accompaniments.

Based on the evaluation of the casework, the review team found that, over the review period,

inspection reports evolved from a checklist format to a performance-based format following IMC

2800 guidance that included focus elements. The majority of inspection reports, however, did

not provide at least one of the following elements: the scope of the licensee’s program,

material possessed at the time of the inspection, authorized locations that were inspected,

observations of licensed activities, or inspector independent survey results.

The review team noted that medical and nuclear pharmacy inspections also did not include any

documentation of iodine-131 procedures. The review team’s evaluation of industrial

radiography license inspections identified that Section inspectors did not document the review 

of radiographer certification cards or whether an inspection had been conducted at a temporary 
Oregon Final Report Page 7

job site. Discussions with inspection staff indicated that performance-based inspections were

conducted, including inspections at temporary job sites, but not always properly documented.

The majority of violations are documented on an Oregon Form 591. In most of the casework

evaluated, specific regulation or licensee procedure support for violations was not included on

the Oregon Form 591 or in the inspection file. The Oregon Form 591 requires the licensee to

provide a written response to the violations. The review team noted that prompt regulatory

actions were not always taken in response to violations identified. Acknowledgment letters

were routinely sent to the licensee more than 30 days after receipt of the licensee’s response. 

The review team recommends that the State place greater emphasis on providing sufficient

detail in inspection reports to allow Section management and staff to understand the technical

basis for inspection findings.

When escalated enforcement is appropriate, the Division has the authority to require

management conferences, suspend licenses, and impound licensed material. Legislation is

currently pending giving the Division authority to levy civil penalties.

Regarding supervisory inspector accompaniments, the team noted that accompaniments are

not performed annually, as required by the Section’s inspection procedures. Of the three staff

members currently assigned to inspection positions, none were accompanied by their

supervisor in 2004. One of the inspectors was accompanied by a supervisor in 2005 and

another was accompanied in 2006. The Acting Program Manager, new to the position, has not

yet accompanied staff on inspections. To increase familiarity with the radioactive materials

program, the newly assigned Lead Worker in the program accompanied two inspectors in 2006. 

The review team and the Section managers discussed the value of annual supervisory

inspector accompaniments. The review team recommends that the State ensure that

radioactive materials inspectors are accompanied by supervisors, at least annually, to promote

quality and consistency in the inspection program.

The Section has adequate quantities and types of radiation detection equipment to support their

radiation protection efforts, with recent upgrades acquired through funding provided by the

Department of Homeland Security. Appropriate and calibrated survey instruments such as

Geiger-Mueller (GM) meters, scintillation detectors, ion chambers, micro-R-meters, and air

samplers were observed. The instrumentation is calibrated annually by Oregon State

University, and air samplers are calibrated by Oregon’s Occupational Health and Safety

Administration Laboratory.

Two Section inspectors were accompanied during inspections by a review team member during

the week of July 23, 2006. Inspection accompaniments included an industrial radiography

facility requiring increased controls and a high dose-rate remote afterloader program. The

accompaniments and associated comments are included in Appendix C. During the

accompaniments, each inspector demonstrated appropriate performance-based inspection

techniques and knowledge of the regulations. The inspectors were appropriately trained,

prepared, and thorough in their audits of the licensees radiation safety programs. Overall, each

inspector utilized good health physics practices. Interviews with licensee personnel were

performed in an effective manner, and the inspections were adequate to assess radiological

health and safety at the licensed facilities. During the industrial radiography inspection, the

inspector, seeing that essential increased controls were not in place, required the licensee to

take immediate compensatory measures until a corporate security evaluation was completed. 
Oregon Final Report Page 8

The inspector’s approach was commendable.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon’s performance with respect to the indicator, Technical Quality of Inspections, was

satisfactory, but needs improvement.

3.4 Technical Quality of Licensing Actions

The review team interviewed license reviewers, evaluated the licensing process, and examined

licensing casework for 22 specific licenses. Twenty-three licensing actions were reviewed for

completeness, consistency, proper radioisotopes and quantities, qualifications of authorized

users, adequate facilities and equipment, adherence to good health physics practices, financial

assurance, operating and emergency procedures, appropriateness of the license conditions,

and overall technical quality. The casework was also reviewed for timeliness, use of

appropriate deficiency letters and cover letters, reference to appropriate regulations, product

certifications, supporting documentation, consideration of enforcement history, pre-licensing

visits, peer and supervisory review as indicated, and proper signatures. The casework was

checked for retention of necessary documents and supporting data.

The casework was selected to provide a representative sample of licensing actions completed

during the review period. The sample included the following license types: medical and

academic broad scope, manufacturing and distribution, medical institution - limited, high doserate remote afterloader, gamma stereotactic radiosurgery, mobile nuclear medicine, nuclear

pharmacy, industrial radiography, and fixed gauge. Types of licensing actions selected for

evaluation included new licenses, renewals, amendments to existing licenses, and license

terminations. A listing of the licensing casework evaluated, with case specific comments, may

be found in Appendix D.

The review team found that the licensing actions were generally thorough, complete, consistent,

and of high quality with health and safety issues properly addressed. License tie-down

conditions were stated clearly, backed by information contained in the file, and inspectible.

Deficiency letters clearly stated regulatory positions, were used at the proper time, and

identified substantive deficiencies in the licensees' documents. The Section has one senior

staff member whose primary responsibility is licensing. At a minimum, each licensing action

has a peer review and a management review. Peer reviews are completed by inspection staff

with expertise in the radioactive material use being licensed. In addition, licenses usually

undergo review by the Program Manager and a final review by the Section Manager. The

Section Manager, or his designated representative, signs all licenses. The review team noted

that the Section has a very efficient and effective licensing process with the exception of the

practice of advance authorizations, as discussed below.

The review team noted that, following the 2002 IMPEP review, the Section continued to issue

advance authorizations for licensing, after an informal health and safety evaluation. Senior staff

members continued to grant these authorizations, which were unspecific as to the requirements

imposed on the licensee or applicant. At the December 3, 2002 MRB meeting, the MRB

members and Oregon program management discussed discontinuing routine use of this

practice until it was fully proceduralized and its legality was confirmed. As of the date of this

review, the development of a procedure and a legal review of the process had not been

accomplished.
Oregon Final Report Page 9

Two advance authorizations were evaluated by the team. The first was a medical center’s

request for authorization to obtain a gamma stereotactic radiosurgery unit. The advance

authorization was issued on July 7, 2006. No health and safety or security instructions were

issued with the authorization. After consultation with the review team, the State opted to issue

a possession-only license to the medical center with appropriate license conditions addressing

this area. The license was issued on August 24, 2006. The second advance authorization,

issued on July 26, 2002, to a testing company, authorized possession of a portable gauge. The 

testing company lost the gauge on September 23, 2002, prior to the issuance of a license on

October 23, 2002.

In light of the health and safety potential for possession and use of these radioactive materials,

and the need for security for the sources, the review team recommends that the

recommendation from the 2002 IMPEP review regarding advance authorizations remain open.

The review team examined the list of licensees that the Section had determined met the criteria

for the increased controls per COMSECY-05-0028. The review team determined that the

Section had correctly identified the Oregon licensees that require increased controls based on

this criteria and have procedures in place to issue increased controls to any additional

licensees, as appropriate. Each licensee was issued a license amendment requiring increased

controls in accordance with the timelines established by the Commission in the Staff

Requirements Memorandum for COMSECY-05-0028.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon's performance with respect to the indicator, Technical Quality of Licensing Actions,

was satisfactory, but needs improvement.

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Section’s actions in responding to incidents, the review

team examined the Section’s response to the questionnaire relative to this indicator, evaluated

selected incidents reported for Oregon in NMED against those contained in the State’s

database and incident files, and evaluated casework and supporting documentation for 14

radioactive material incidents. A listing of the incident casework examined, with case-specific

comments, is included in Appendix E. The review team also evaluated the Section’s response

to allegations involving radioactive materials, including one allegation referred to the State by

the NRC. Incident and allegation policies, file documentation, the Section’s incident and

allegation tracking system, NMED, and notification of incidents to the NRC Headquarters

Operations Center were discussed with Section management and staff.

The review team found incident information was maintained in several locations: the license

files, the Section’s database, the incident files, the NMED files, and the inspectors’ personal

files. In most cases, no single file had all of the pertinent documents. The review team found

the Section’s documentation was often incomplete, and in some cases, the investigation results

were missing from both the database and the license files and had to be found in other

locations (e.g., staff personal files).

Written procedures exist for handling incidents. When notified of an incident after hours, the

information is received by a 24-hour emergency response system. The information is recorded

on a incident report summary form, and the individual on call is notified. After notification of an
Oregon Final Report Page 10

incident, Section supervisors determine if the event requires a call to the NRC Headquarters

Operations Center. A member of the inspection staff is assigned to investigate the incident and

to complete any required followup activities.

During the review period, the Section received reports of 27 radioactive material incidents. The

review team evaluated 14 incidents that required reporting under NRC criteria. The incidents

selected for review included the following categories: overexposure, lost/stolen radioactive

material, damaged gauge, and medical event. When investigations were conducted, initial

responses were prompt and the level of effort was commensurate with the health and safety

significance. Several exceptions are noted below.

The review team determined that 9 of the 14 incidents evaluated had not been reported to

NMED as required. The review team identified four incidents that had not been completed or

closed out in NMED, although the review of incident files revealed that inspections and

follow-up actions were performed. The unreported and open incidents were discussed with the

Section managers, who agreed to contact the NRC contractor responsible for maintaining

NMED to complete and close the identified incidents. During the on-site review, the Section

took the necessary actions to submit the requisite information to the NRC Headquarters

Operation Center and to the NRC’s contractor responsible for maintaining NMED to enter or

close all unreported or incomplete incidents, respectively.

After reviewing the incident documentation, the review team determined that the Section

dispatched inspectors for on-site investigations and took appropriate followup actions in all but

four cases. The first instance, in October 2005, related to a reported gamma stereotactic

radiosurgery medical event involving a 32 gray (3,200 rad) dose to the wrong treatment site. A

reactive inspection was not conducted at that time. The incident was mistakenly identified by a

Section supervisor as a 32 rad dose instead of the much higher 32 gray dose. The licensee’s

incident report was apparently not reviewed by any other Section staff members. The Section

contacted the licensee to discuss the incident during the IMPEP review. Subsequent to the

IMPEP review, the Section conducted a followup inspection and discovered that the incident

was due to a physician’s prescription error and did not meet the NRC’s reporting criteria. In

another instance, a stolen gauge, the event report was not in the license file; therefore, no

followup occurred at the next inspection of that licensee.

The final two instances involved the loss of control of radioactive material. These incidents

involved improper disposal of iodine-125 seed implants and a vial containing 237 microcuries of

iodine-125 labeled hormones. The Section knew of the incidents, but because of the low

activities involved, and the likely wrong disposal locations of the material (landfill, sewer), the

Section did not believe that any followup or enforcement action was necessary. Under the

NRC’s enforcement program, these incidents would likely be considered for followup and

enforcement actions. The review team recommends that the State take measures to ensure

proper documentation and appropriate response, review, enforcement, and followup of all

radioactive materials incidents.

During the review period, the Section received four allegations involving Agreement material.

The review team evaluated the casework for all four allegations, one of which was referred to

the State by the NRC. The review team’s evaluation indicated that prompt and appropriate

action was taken in response to the concerns raised. Allegers requesting anonymity were

informed that every effort would be made to protect his/her identity, but could not be
Oregon Final Report Page 11

guaranteed. Each of the allegations reviewed were appropriately closed, and the allegers were

informed of the results, when possible. There were no performance issues identified from the

review of the allegation casework documentation.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon’s performance with respect to the indicator, Technical Quality of Incident and

Allegation Activities, was satisfactory, but needs improvement.

4.0 NON-COMMON PERFORMANCE INDICATORS

IMPEP identifies four non-common performance indicators to be used in reviewing Agreement

State programs: (1) Compatibility Requirements, (2) Sealed Source and Device Evaluation

Program, (3) Low-Level Radioactive Waste Disposal Program, and (4) Uranium Recovery

Program. Only the performance indicators, Compatibility Requirements and Low-Level

Radioactive Waste Disposal Program, were applicable to this review.

4.1 Compatibility Requirements

4.1.1 Legislation

Oregon became an Agreement State on June 22, 1965. Legislative authority to create an

agency and enter into an Agreement with the NRC is granted in Oregon Statute 453.625. 

Oregon Statute 453 governs the use of radioactive materials, x-ray, emergency response and

laboratory services. The Section is designated as the State's radiation control agency. There

were no legislative changes during the review period. Oregon has no sunset provisions either

for the Section or for its regulations.

4.1.2 Program Elements Required for Compatibility

The State’s regulations governing radiation protection requirements are contained in the

Oregon Administrative Rules (OAR) 333. Oregon requires a license for the possession and use

of all radioactive material, including NARM. Oregon also requires registration of all machines

designed to produce radiation.

The review team evaluated the Section’s response to the questionnaire relative to this indicator,

reviewed the status of regulations required to be adopted by the State under the Commission’s

adequacy and compatibility policy, and verified the adoption of regulations with data obtained

from the NRC’s STP State Regulation Status Data Sheet.

Since the previous IMPEP review, the Section has addressed a large number of NRC regulation

amendments. The first package containing 25 final amendments was received December 3,

2002. In a letter dated January 23, 2003, the NRC transmitted comments concerning the

Oregon final regulations and requested that when these comments become incorporated into

the rules, a copy of the final, as published, version of the rules be sent to NRC. The rules

became effective on March 27, 2003. The second package received on May 18, 2006,

contained 9 proposed amendments. In a letter dated July 10, 2006, the NRC transmitted 30

comments concerning the Oregon proposed regulations and also requested that when these

comments become incorporated into the rules, a copy be sent to NRC. These rules became

effective on June 16, 2006. Eighteen of the NRC comments regarded the General License
Oregon Final Report Page 12

rule, and 11 of those comments were held in abeyance pending the determination of the

adequacy and compatibility of those rules, as Oregon has the essential elements of the NRC’s

rule and is more restrictive than the NRC’s rule.

As of the date of this review, the Section had not submitted any of the requested regulations to

the NRC for a final compatibility review. Furthermore, 23 of these amendments were adopted

from one to seven years later than the three-year time frame required after the effective date of

NRC’s final rule. Under NRC’s current procedure, a finding that a State’s regulations meet the

compatibility and health and safety categories of the equivalent NRC regulations is based on a

review of the final State regulations and the adoption of the regulations in the three-year time

frame after the effective date of NRC’s final rule.

The Section Manager indicated that the NRC comments on the final and proposed regulations

were incorporated in their effective regulations. The review team found that with the exception

of two, all comments have been incorporated into the regulations adopted on June 16, 2006. 

The Section committed to submitting the final regulations to the NRC using STP Procedure SA201 “Review of State Regulatory Requirements” as a guide. The review team recommends that

the State develop and implement an action plan to adopt NRC regulations in accordance with

current NRC policy on adequacy and compatibility.

The review team noted that the following requirement was incorporated by license condition

since the last IMPEP review:

! “Increased Controls for Risk-Significant Radioactive Sources,” NRC Order EA-05-090

(70 FR 72128) that became effective December 1, 2005.

The following proposed regulations were submitted to the NRC for review and comment. By

letter dated July 16, 2006, NRC responded to the submission with 30 comments:

! “Respiratory Protection and Controls to Restrict Internal Exposure,” 10 CFR Part 20

amendment (64 FR 54543 and 64 FR 55524) that became effective February 2, 1999.

! “Energy Compensation Sources for Well Logging and Other Regulatory Clarifications,”

10 CFR Part 39 amendment (65 FR 20337) that became effective on May 17, 2000.

! “New Dosimetry Technology,” 10 CFR Parts 34, 36, and 39 amendments (65 FR 63750)

that became effective on January 8, 2001.

! “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

Material,” 10 CFR Parts 30, 31, 32 amendments (65 FR 79162) that became effective

on February 16, 2001.

! “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 16298) that

became effective on April 5, 2002.

! “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32, and 35 amendments 

(67 FR 20249) that became effective on October 24, 2002.

! “Financial Assurance for Materials Licensees,” 10 CFR Parts 30, 40, and 70
Oregon Final Report Page 13

amendments (68 FR 57327) that became effective on December 3, 2003.

! “Medical Use of Byproduct Material - Recognition of Specialty Boards,” 10 CFR Part 35

amendment (70 FR 16336, 71 FR 1926) that became effective on April 29, 2005.

! “Security Requirements for Portable Gauges Containing Byproduct Material,” 10 CFR

Part 30 amendment (70 FR 2001) that became effective on July 11, 2005.

The Section will need to address the following regulations in upcoming rulemakings or by

adopting alternate legally binding requirements by the date indicated:

! “Compatibility with IAEA Transportation Safety Standards and Other Transportation

Safety,” 10 CFR Part 71 amendment (69 FR 3697) that became effective on October 1,

2004 and is due for State adoption by October 1, 2007.

! “Minor Amendments - 10 CFR Parts 20, 30, 32, 35, 40 and 70," 10 CFR amendments

(71 FR 15005) that became effective March 27, 2006 and are due for State adoption by

March 27, 2009.

It should be noted that the Section expended considerable effort in regulation development

during the review period. As discussed in Section 3.1 of this report, the former Program

Manager was assigned full-time responsibility and oversight for rulemaking actions and

regulations. The Section Manager expects that all required regulations will be adopted and

approved by the NRC by the end of the year.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Oregon’s performance with respect to the indicator, Compatibility Requirements, was

satisfactory, but needs improvement.

4.2 Low-Level Radioactive Waste (LLRW) Disposal Program

In 1981, the NRC amended its Policy Statement, "Criteria for Guidance of States and NRC in

Discontinuance of NRC Authority and Assumption Thereof by States Through Agreement" to

allow a State to seek an amendment for the regulation of LLRW as a separate category. Those

States with existing Agreements prior to 1981 were determined to have continued LLRW

disposal authority without the need of an amendment. Although Oregon has such disposal

authority, NRC has not required States to have a program for licensing a disposal facility until

such time as the State has been designated as a host State for a LLRW disposal facility. When

an Agreement State has been notified or becomes aware of the need to regulate a LLRW

disposal facility, they are expected to put in place a regulatory program which will meet the

criteria for an adequate and compatible LLRW disposal program. There are no plans for a

LLRW disposal facility in Oregon. Accordingly, the review team did not evaluate this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, Oregon’s performance was found to be satisfactory for two

performance indicators, and satisfactory, but needs improvement, for the performance

indicators, Technical Quality of Inspections, Technical Quality of Licensing Actions, Technical

Quality of Incident and Allegation Activities, and Compatibility Requirements. Accordingly, the
Oregon Final Report Page 14

review team recommended and the MRB agreed that the Oregon Agreement State Program is

adequate, but needs improvement and compatible with NRC's program. The review team

recommended and the MRB agreed that a period of Heightened Oversight should be

implemented to assess the progress of the State addressing the recommendations from this

review. The period of Heightened Oversight will include the development of a program

improvement plan, bimonthly conference calls, and a followup IMPEP review in approximately

one year from the date of this review.

Below is a summary list of recommendations, as mentioned in earlier sections of the report, for

evaluation and implementation by the State. Included is one open recommendation from the

2002 IMPEP report:

RECOMMENDATIONS:

1. The review team recommends that the State place greater emphasis on providing

sufficient detail in inspection reports to allow Section management and staff to

understand the technical basis for inspection findings. (Section 3.3)

2. The review team recommends that the State ensure that radioactive materials

inspectors are accompanied by supervisors, at least annually, to promote quality and

consistency in the inspection program. (Section 3.3)

3. The review team recommends that the Section discontinue the routine use of advance

authorizations pending development of a procedure and basis for issuing the

authorizations. Once developed, the Section should have the practice of issuing

advance authorization and the procedure reviewed by counsel and its Radiological

Advisory Committee. The review should include the form and content of the

authorizations, the legal basis for issuing notifications prior to issuance of a license, as

well as a determination of the potential impact on health and safety issues. In addition,

the review should determine the State’s potential liability and the compatibility of the

practice with established State and Federal regulations, including requirements imposed

on distributors of devices containing radioactive material. (From 2002 IMPEP review)

(Section 3.4)

4. The review team recommends that the State take measures to ensure proper

documentation and appropriate response, review, enforcement, and followup of all

radioactive materials incidents. (Section 3.5)

5. The review team recommends that the State develop and implement an action plan to

adopt NRC regulations in accordance with current NRC policy on adequacy and

compatibility. (Section 4.1.2)
LIST OF APPENDICES AND ATTACHMENT

Appendix A IMPEP Review Team Members

Appendix B Oregon Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment October 19, 2006, Letter from Terry Lindsey

Oregon’s Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

James Lynch, RIII Team Leader

Status of Materials Inspection Program

Inspector Accompaniments

Andrea Jones, STP Technical Staffing and Training

Robert Hays, RIII Technical Quality of Inspections

Mark Light, Ohio Technical Quality of Licensing Actions

Linda McLean, RIV Technical Quality of Incident and Allegation Activities

Compatibility Requirements
APPENDIX B

OREGON ORGANIZATION CHARTS

ADAMS: ML062480465

Pages: 1 - 3
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Acuren Inspection, Inc. License No.: ORE-90621

Inspection Type: Increased Controls, Announced Priority: 1

Inspection Date: 5/3/06 Inspectors: KS, JS

File No.: 2

Licensee: PCC Stucturals, Inc. License No.: ORE-90232

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 1/20/06 Inspector: JS

Comments:

a) Management review was completed six months after the inspection, with no comments.

b) No inspection report in file for December 2002 inspection as a reference for inspectors.

c) Inspection report did not include program scope and what is actually possessed at any

of the eight authorized locations.

File No.: 3

Licensee: Portland State University License No.: ORE-90156

Inspection Type: Routine, Announced Priority: 3

Inspection Date: 9/24/04 Inspector: JS

Comments:

a) Licensee response received one year after the inspection.

b) Violations on Form 591 did not specify what requirements were specifically violated. 

c) Management review of the inspection report performed one year after the inspection,

with no comments.

d) Inspection report did not comment on the licensee’s use of an expired waste manifest

for a waste shipment.

File No.: 4

Licensee: Cardinal Health License No.: ORE-90509

Inspection Type: Not specified on inspection report Priority: 1

Inspection Date: 3/29/06 Inspector: KS

Comments:

a) Only unrestricted area independent surveys documented.

b) No iodine-131 inspection activities documented, however, I-131 uptakes were indicated

on dosimetry records.

c) No documentation of licensee audit results.

d) No documentation pertaining to radiopharmaceutical dispensing errors.

e) Nuclear pharmacy staff dosimetry records in file without redaction of personal

information.
Oregon Final Report Page C.2

Inspection Casework Reviews

File No.: 5

Licensee: Legacy Emanuel Hospital License No.: ORE-90014

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 9/15/05 Inspector: JS

Comments:

a) Brachytherapy procedures not inspected.

b) No documentation of I-131 use, if any.

c) Dosimetry records for nuclear medicine technologist not available. No reason stated.

d) Personnel dosimetry badges not exchanged as required. No violation cited, nor a

reason why a violation was not cited.

e) Management review of the inspection report performed nine months after the inspection,

with no comments.

File No.: 6

Licensee: Samaritan Lebanon Community Hospital License No.: ORE-90990

Inspection Type: Initial, Unannounced Priority: 3

Inspection Date: 8/29/03 Inspector: KS

Comments:

a) No scope of licensed activities identified in report.

b) Only one individual contacted during inspection; RSO not contacted.

File No.: 7

Licensee: Community Cancer Center License No.: ORE-90422

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 3/9/05 Inspector: JS

Comments:

a) Inspection record indicated a declared pregnant female received 960 mrem Deep Dose

Equivalent in June 2004, no other specific information provided.

b) Inspection report indicated nuclear pharmacist on staff, but no radiopharmaceuticals

administered.

c) Inspection report indicated the licensee has a high dose-rate afterloader, but no other

information provided.

d) Management review of the inspection report performed five months after the inspection,

with no comments.

File No.: 8

Licensee: International Inspection License No.: ORE-90651

Inspection Type: Not specified on Inspection Report Priority: 1

Inspection Date: 8/10/05 Inspector: KS

Comment:

No detail about the violation cited on Form 591.
Oregon Final Report Page C.3

Inspection Casework Reviews

File No.: 9

Licensee: Acuren Inspection, Inc. License No.: ORE-90621

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 7/27/06 Inspector: JS

Comment:

No information provided about temporary job site work, if any.

File No.: 10

Licensee: Central Oregon Community Hospital License No.: ORE-90510

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 10/1/03 Inspector: JS

Comment:

Licensee response dated October 31, 2003, acknowledgment letter dated July 30, 2004.

File No.: 11

Licensee: University of Portland License No.: ORE-90934

Inspection Type: Routine, Unannounced Priority: 5

Inspection Date: 5/24/06 Inspector: KS

Comment:

The violation indicated on the Form 591 was not a specific requirement in the licensee’s

procedures.

File No.: 12

Licensee: St. Vincent Hospital and Medical Center License No.: ORE-90104

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 9/8/05 Inspector: JS

Comment:

A portable gauge program checklist used as part of the inspection of this medical

license.

File No.: 13

Licensee: Northwest Equine Performance License No.: ORE-90968

Inspection Type: Routine, Announced Priority: 3

Inspection Date: 2/27/06 Inspector: JS

Comments:

a) No close out surveys provided by the licensee to indicate no contamination at the

previous address before released for unrestricted use.

b) Violations not clear on the Form 591. Violations not detailed in the inspection report.
Oregon Final Report Page C.4

Inspection Casework Reviews

File No.: 14

Licensee: Salem Hospital License No.: ORE-91006

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 3/17/04 Inspector: JS

Comments:

a) Inspection report was completed four months after the inspection.

b) Inspection information in file not clear about when the next inspection is due.

File No.: 15

Licensee: Oncology Associates of Oregon License No.: ORE-91030

Inspection Type: Initial, Unannounced Priority: 3

Inspection Date: 3/29/05 Inspector: KS

Comments:

a) No performance-based inspection information provided in the inspection report. 

b) No information about authorized locations listed on the license.

INSPECTOR ACCOMPANIMENTS

The following inspector accompaniments were performed prior to the on-site IMPEP review:

Accompaniment No.: 1

Licensee: Oncology Associates of Oregon License No: ORE-90862

Inspection Type: Routine, Announced Priority: 2

Inspection Date: 7/27/06 Inspector: KS

Comment:

The inspector missed an opportunity to interview technologists, dosimetrists and

ancillary personnel.

Accompaniment No.: 2

Licensee: Professional Service Industries, Inc. License No: ORE-90056

Inspection Type: Increased Controls, Announced Priority: 1

Inspection Date: 7/28/06 Inspector: JS

Comment:

The inspector identified the licensee’s lack of Increased Controls and required the

licensee to immediately implement compensatory measures.
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Oregon Health and Science Center License No.: ORE-90980

Type of Action: Termination Amendment No.: 7

Date Issued: 3/31/06 License Reviewer: SM

File No.: 2

Licensee: Oregon Health Sciences University License No.: ORE-90731

Type of Action: Amendment Amendment No.: 68

Date Issued: 11/23/05 License Reviewer: SM

File No.: 3

Licensee: Oregon Health Sciences University License No.: ORE-90731

Type of Action: Amendment Amendment No.: 69

Date Issued: 1/18/06 License Reviewer: SM

File No.: 4

Licensee: Oregon State University License No.: ORE-90005

Type of Action: Amendment Amendment No.: 80

Date Issued: 11/23/05 License Reviewer: SM

File No.: 5

Licensee: Oregon Health and Science University License No.: ORE-90013

Type of Action: Renewal Amendment No.: 90

Date Issued: 12/1/03 License Reviewer: SM

File No.: 6

Licensee: Sacred Heart Medical Center License No.: ORE-91054

Type of Action: New Amendment No.: N/A

Date Issued: 7/7/06 License Reviewer: SM

Comments:

a) An advance authorization was issued to possess and use radioactive material. Neither

the procedural basis, the health and safety review, or security issues for the advance

authorization were clearly documented in the file.

b) A possession-only license was issued on August 24, 2006.

File No.: 7

Licensee: Oncology Associates of Oregon License No.: ORE-90862

Type of Action: Amendment Amendment No.: 11

Date Issued: 7/31/06 License Reviewer: SM
Oregon Final Report Page D.2

Licensing Casework Reviews

File No.: 8

Licensee: Cardinal Health License No.: ORE-90509

Type of Action: Amendment Amendment No.: 36

Date Issued: 8/17/06 License Reviewer: SM

Comment:

The license was issued on August 17, 2006, however, the signature date indicated

August 26, 2006.

File No.: 9

Licensee: Providence Portland Medical Center License No.: ORE-90053

Type of Action: Renewal Amendment No.: 90

Date Issued: 4/30/03 License Reviewer: SM

File No.: 10

Licensee: Reed College License No.: ORE-90010

Type of Action: Renewal Amendment No.: 51

Date Issued: 8/30/05 License Reviewer: SM

File No.: 11

Licensee: PCC Structurals, Inc. License No.: ORE-90232

Type of Action: Renewal Amendment No.: 59

Date Issued: 8/16/06 License Reviewer: SM

File No.: 12

Licensee: Legacy Health System License No.: ORE-90008

Type of Action: Renewal Amendment No.: 83

Date Issued: 6/24/03 License Reviewer: SM

File No.: 13

Licensee: Comprehensive Cancer Center License No.: ORE-90790

Type of Action: Renewal Amendment No.: 16

Date Issued: 12/21/05 License Reviewer: SM

File No.: 14

Licensee: OGI School of Science and Engineering License No.: ORE-90676

Type of Action: Termination Amendment No.: 51

Date Issued: 2/20/03 License Reviewer: SM

File No.: 15

Licensee: Samaritan Lebanon Community Hospital License No.: ORE-90990

Type of Action: New Amendment No.: N/A

Date Issued: 2/24/03 License Reviewer: SM

File No.: 16

Licensee: Cascade Health Services License No.: ORE-90979

Type of Action: New Amendment No.: N/A

Date Issued: 2/21/03 License Reviewer: SM
Oregon Final Report Page D.3

Licensing Casework Reviews

File No.: 17

Licensee: Oregon Advanced Imaging License No.: ORE-91001

Type of Action: New Amendment No.: N/A

Date Issued: 2/18/03 License Reviewer: SM

File No.: 18

Licensee: Pacific Technical Industries, Inc. License No.: ORE-90779

Type of Action: Termination Amendment No.: 12

Date Issued: 4/7/05 License Reviewer: SM

File No.: 19

Licensee: Northwest Inspection, Inc. License No.: ORE-90889

Type of Action: Termination Amendment No.: 13

Date Issued: 8/18/05 License Reviewer: SM

File No.: 20

Licensee: St. Vincent Hospital and Medical Center License No.: ORE-90965

Type of Action: Termination Amendment No.: 2

Date Issued: 8/16/04 License Reviewer: SM

File No.: 21

Licensee: Southern Oregon Rock, LLC License No.: ORE-91008

Type of Action: New Amendment No.: N/A

Date Issued: 6/3/03 License Reviewer: DL

File No.: 22

Licensee: P.E.T. Imaging Services, LLC License No.: ORE-91007

Type of Action: Amendment Amendment No.: 7

Date Issued: 6/16/05 License Reviewer: JS

File No.: 23

Licensee: ACS Testing License No.: ORE-90987

Type of Action: New Amendment No.: N/A

Date Issued: 7/26/02 License Reviewer: SM

Comments:

a) An advance authorization was issued for possession and use of radioactive material.

Neither the procedural basis, the health and safety review, or security issues for the

advance authorization were clearly documented in the file. The licensee lost the

portable gauge on September 23, 2002, prior to the license being issued.

b) A license was issued on October 23, 2002.
APPENDIX E

INCIDENT CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Cardinal Health Pharmacy License No.: ORE-90914

Date of Incident: 1/5/06 Event No.: 06-0001

Investigation Date: 1/5/06 Type of Incident: Vehicle Accident

Type of Investigation: Telephone

Comment:

Not reported to NMED.

File No.: 2

Licensee: Geo Pacific Testing, Inc. License No.: ORE-90950

Date of Incident: 3/4/05 Event No.: 05-0013

Investigation Date: 3/8/05 Type of Incident: Stolen Gauge

Type of Investigation: On-site

Comments:

a) Not reported to NMED.

b) No followup during the next inspection because the event report was not in the license

file.

File No.: 3

Licensee: Oregon Health & Science University License No.: ORE-90731

Date of Incident: 2/28/06 Event No.: 06-0005

Investigation Date: N/A Type of Incident: Lost Source

Type of Investigation: N/A

Comment:

Not reported to NMED.

File No.: 4

Licensee: Geo Engineering License No.: ORE-90987

Date of Incident: 6/3/05 Event No.: 05-0037, NMED No.: 020901

Investigation Date: N/A Type of Incident: Stolen Gauge

Type of Investigation: N/A

Comment:

Inspection was not conducted because the gauge was found the same day. To be

followed-up at the next inspection.
Oregon Final Report Page E.2

Incident Casework Reviews

File No.: 5

Licensee: Kaiser Sunnyside Hospital License No.: ORE-90464

Date of Incident: 8/22/05 Event No.: 05-0062

Investigation Date: N/A Type of Incident: Medical

Type of Investigation: N/A

Comments:

a) No followup inspection conducted. Event was due to an equipment software problem.

b) Not reported to NMED.

File No.: 6

Licensee: Providence Portland Medical Center License No.: ORE-90946

Date of Incident: 10/3/05 Event No.: 05-0072

Investigation Date: N/A Type of Incident: Medical

Type of Investigation: N/A

Comments:

a) May be an Abnormal Occurrence report.

b) Followup inspection scheduled for August 30, 2006.

c) Not reported to the NRC’s Headquarters Operations Center or to NMED.

File No.: 7

Licensee: Longview Inspection License No.: ORE-90621

Date of Incident: 3/23/04 Event No.: 04-0013

Investigation Date: 3/23/04 Type of Incident: Potential Overexposure

Type of Investigation: On-site

Comment:

Not reported to NMED.

File No.: 8

Licensee: Geo Pacific Engineering License No.: ORE-90605

Date of Incident: 11/3/03 Event No.: 03-0063, NMED No.: 030909

Investigation Dates: 11/5/03, 12/22/03, 2/11/04 Type of Incident: Stolen Gauge

Type of Investigations: On-site

File No.: 9

Licensee: Meridian Park Hospital License No.: ORE-90293

Date of Incident: 5/30/03 Event No.: 03-0064

Investigation Date: N/A Type of Incident: Medical: N/A

Type of Investigation: N/A

Comments:

a) No followup inspection conducted. The incident involved an administration to the wrong

patient.

b) Not reported to NMED.
Oregon Final Report Page E.3

Incident Casework Reviews

File No.: 10

Licensee: Longview Inspection License No.: ORE-90621

Date of Incident: 2/18/03 Event No.: 03-0008

Investigation Date: 2/18/03 Type of Incident: Overexposure

Type of Investigation: On-site

Comment:

Not reported to NMED.

File No.: 11

Licensee: Rogue Valley Medical Center License No.: ORE-90064

Date of Incident: 3/10/03 Event No.: 03-0010, NMED No.: 030201

Investigation Date: 3/12/03 Type of Incident: Medical

Type of Investigation: On-site

File No.: 12

Licensee: Geo Pacific Testing, Inc. License No.: ORE-90950

Date of Incident: 9/23/02 Event No.: 02-0037, NMED No.: 020901

Investigation Date: 9/23/02 Type of Incident: Lost Gauge

Type of Investigation: On-site

File No.: 13

Licensee: Geocon Northwest License No.: ORE-90921

Date of Incident: 10/15/02 Event No.: 02-0041, NMED No.: 020953

Investigation Date: 10/16/02 Type of Incident: Lost gauge

Type of Investigation: On-site

File No.: 14

Licensee: Providence St. Vincent Medical Center License No.: ORE-90104

Date of Incident: 12/30/02 Event No.: 02-0055

Investigation Date: 12/31/02 Type of Incident: Medical

Type of Investigation: On-site

Comment:

Not reported to NMED.
ATTACHMENT

October 19, 2006, Letter from Terry Lindsey

Oregon’s Response to Draft IMPEP Report

ADAMS: ML062970179