January 29, 2008 

Mr. Thomas P. Hogan, Manager 

Indoor Environments and Radiation Section 

Division of Environmental Health 

Minnesota Department of Health 

P. O. Box 64975 

St. Paul, MN 55164-0975 

Dear Mr. Hogan: 

On January 8, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Minnesota 

Agreement State Program. The MRB found the Minnesota Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 4.0, page 9, of the enclosed final report contains a summary of the IMPEP review 

team=s findings. Based on the results of the current IMPEP review, the next full review of the 

Minnesota Agreement State Program will take place in approximately 4 years, with a periodic 

meeting tentatively scheduled for October 2009. 

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

I also wish to acknowledge your continued support for the Agreement State 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: 

Minnesota Final IMPEP Report 

cc w/enclosure: 

George Johns, Supervisor 

Minnesota Radioactive Materials Program 

Dennis O’Dowd, New Hampshire 

Organization of Agreement States 

 Liaison to the MRB
January 29, 2008 

Mr. Thomas P. Hogan, Manager 

Indoor Environments and Radiation Section 

Division of Environmental Health 

Minnesota Department of Health 

P. O. Box 64975 

St. Paul, MN 55164-0975 

Dear Mr. Hogan: 

On January 8, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Minnesota 

Agreement State Program. The MRB found the Minnesota Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 4.0, page 9, of the enclosed final report contains a summary of the IMPEP review 

team=s findings. Based on the results of the current IMPEP review, the next full review of the 

Minnesota Agreement State Program will take place in approximately 4 years, with a periodic 

meeting tentatively scheduled for October 2009. 

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

I also wish to acknowledge your continued support for the Agreement State 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: 

Minnesota Final IMPEP Report 

cc w/enclosure: 

George Johns, Supervisor 

Minnesota Radioactive Materials Program 

Dennis O’Dowd, New Hampshire 

Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: EDATS: FSME-2008-0001 

See next page. 

ML080150146 

OFFICE FSME/DMSSA FSME/DMSSA FSME/DMSSA 

NAME ATMcCraw:kk ADWhite RJLewis 

DATE 01/15/08 01/16/08 01/16/08 

OFFICE Tech Editor FSME EDO/DEDMRT 

NAME CPoland CLMiller MJVirgilio 

DATE 01/17/08 01/24/08 01/29/08 

OFFICIAL RECORD COPY
LETTER TO THOMAS P. HOGAN FROM MARTIN J. VIRGILIO DATED: January 29, 2008 

Distribution: 

DMSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Klein 

KLukes, FSME/DMSSA Commissioner Jaczko 

LMcLean, RIV Commissioner Lyons 

JLynch, RIII/RSAO SECY 

MBeardsley, RI 

RErickson, RIV 

Tobias Lickerman, NY 

DDiaz-Toro, OEDO 

KCyr, OGC 

BJones, OGC 

MDapas, RI 

GPangburn, FSME 

APowell, OCA (2 copies) 
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE MINNESOTA AGREEMENT STATE PROGRAM 

October 15-19, 2007 

FINAL REPORT

ENCLOSURE 
Minnesota Final Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of October 15-19, 2007, by a review team comprised of 

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

New York. 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 March 31, 2006, to October 19, 2007, were discussed with 

Minnesota managers on the last day of the review. 

A draft of this report was issued to Minnesota for factual comment on November 16, 2007. The 

State responded by e-mail on December 7, 2007, from George Johns, Supervisor, Radioactive 

Materials Program (the Program). A copy of the State’s response is included as the Attachment 

to this report. The Management Review Board (MRB) met on January 8, 2008, to consider the 

proposed final report. The MRB found the Minnesota Agreement State Program to be adequate 

to protect public health and safety and compatible with NRC’s program. 

The Minnesota Department of Health (the Department) is designated as the State’s radiation 

control agency. The Program, located within the Indoor Environments and Radiation Section 

(the Section), administers the Agreement State program. The Section is part of the Division of 

Environmental Health (the Division), within the Health Protection Bureau (the Bureau). The 

Bureau is one of four bureaus in the Department. Organization charts for the Department, the 

Division, and the Section are included as Appendix B. 

At the time of the review, the Program regulated approximately 185 specific licenses. 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 

Minnesota. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on July 19, 2007. The Program 

provided its response to the questionnaire on August 13, 2007. A copy of the questionnaire 

response may be found in the NRC’s Agencywide Documents Access and Management System 

(ADAMS) using the Accession Number ML072410053. 

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

the Program’s response to the questionnaire; (2) review of applicable Minnesota statutes and 

regulations; (3) analysis of quantitative information from the Program’s database; (4) technical 

review of selected regulatory actions; (5) four field accompaniments of three of the Program’s 

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. 
Minnesota Final Report Page 2 

Results of the review for the common performance indicators are presented in Section 2.0. 

Section 3.0 details the results of the review of the applicable non-common performance 

indicator, and Section 4.0 summarizes the review team's findings. 

2.0 COMMON PERFORMANCE INDICATORS 

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

and Agreement State radioactive materials 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. 

2.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Program’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 Program’s questionnaire response relative to this 

indicator; interviewed Program managers and staff; and reviewed job descriptions, training 

plans, and training records. The review team also considered any possible workload backlogs 

in evaluating this indicator. 

The Supervisor, who heads the Program, is responsible for coordinating materials inspections, 

licensing, and compliance activities. The Program consists of the Supervisor, four radiation 

specialists, and one administrative assistant. The Program’s responsibilities also include 

emergency response activities. The Program has three levels of radiation specialists with each 

level requiring more comprehensive responsibilities. 

The Program has a documented training plan that is consistent with the guidance in the NRC’s 

Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in the Nuclear Materials 

Safety and Safeguards Program Area.” The staff also has on-the-job training to supplement the 

course work. Under the direction of the Supervisor, staff members are assigned increasingly 

complex licensing actions and accompany more experienced inspectors on complicated 

inspections. Inspectors are assigned independent inspections after demonstrating competence 

during accompaniment evaluations by the Supervisor. The review team confirmed the 

qualifications of all staff through review of qualification journals, training records, and 

documentation of supervisory accompaniments. Four staff members, including the Supervisor, 

attended the NRC’s Security Systems and Principles Course. The review team concluded that 

Program managers are supportive of staff training opportunities. 

All technical staff members are fully qualified to perform both licensing and inspection activities 

and have completed the required training in each of these areas. The Program has not 

experienced any turnover since becoming an Agreement State; therefore, at the time of the 

review, the Program was fully staffed. The review team concluded that the Program had an 

adequate number of staff members to carry out its regulatory responsibilities. 

Minnesota licensees are assessed an annual fee and a fee for license amendments. The 

review team noted that the Program had stable funding during the review period. 
Minnesota Final Report Page 3 

The State of Minnesota does not have an oversight board or committee to provide direction to 

the Agreement State program. 

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

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

satisfactory. 

2.2 Status of Materials Inspection Program

The review team focused on five factors while reviewing this indicator: inspection frequency, 

overdue inspections, initial inspections of new licenses, timely dispatch of inspection findings to 

licensees, and performance of reciprocity inspections. The review team’s evaluation was based 

on the Program’s questionnaire response relative to this indicator, data gathered from the 

Program’s database, examination of completed inspection casework, and interviews with 

Program managers and staff. 

The review team verified that the Program’s inspection priorities for various license types are at 

least as frequent as similar license types listed in IMC 2800, “Materials Inspection Program.” In 

response to the questionnaire, the Program indicated that there was one routine inspection 

overdue. The Program completed the inspection prior to the on-site portion of this review. 

Initial inspections were scheduled and conducted within one year of license issuance, with one 

exception. One initial inspection was conducted one month overdue. The initial inspection was 

performed overdue because the Program was not aware that the license issued by the NRC 

prior to the transfer of regulatory authority was a new license; therefore, the inspection was 

incorrectly scheduled in the Program’s database. No inspections were overdue at the time of 

the IMPEP review. 

The review team determined that during the review period, the Program conducted 

approximately 31 Priority 1, 2, and 3 inspections, based on the inspection frequencies 

established in IMC 2800. In addition, the Program performed 19 initial inspections during the 

review period. Overall, the review team calculated that 4 percent of all Priority 1, 2, and 3 and 

initial inspections conducted by the Program during the review period were performed overdue. 

The review team evaluated the timeliness of the issuance of inspection findings through the 

review of inspection casework. The review team found that inspection findings letters were 

routinely sent to licensees within 30 days of the inspection date. Inspection reports are 

completed by the inspectors and undergo peer reviews before being sent to the Supervisor for 

final review and signature. 

During the review period, the Program granted 52 reciprocity permits to candidate licensees 

based on the criteria in IMC 1220, “Processing of NRC Form 241 and Inspection of Agreement 

State Licensees Operating under 10 CFR 150.20.” The review team determined that the 

Program exceeded the NRC’s goal of inspecting 20 percent of candidate licensees operating 

under reciprocity during this review period. 

The review team determined that the Program adequately planned for the initial set of Increased 

Controls inspections of affected licensees. The review team evaluated the Program’s 

prioritization methodology and found it acceptable. The Program identified 23 licensees subject 
Minnesota Final Report Page 4 

to the Increased Controls. The Program completed all of its Increased Controls inspections by 

June 2007. 

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

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

Program, was satisfactory. 

2.3 Technical Quality of Inspections

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

notes, and interviewed inspectors for 21 radioactive materials inspections conducted during the 

review period. The casework reviewed included inspections conducted by six of the Program’s 

staff members and covered inspections of various license types, including: broadscope 

medical, medical - written directive required, medical - private practice, fixed and portable 

gauges, industrial radiography, broadscope academic, irradiator, medical - therapy, nuclear 

pharmacy, manufacturer and distribution, Increased Controls, and reciprocity. Appendix C lists 

the inspection casework files reviewed, with case-specific comments, as well as the details of 

the inspector accompaniments. 

Based on the evaluation of casework, the review team noted that inspections covered all 

aspects of licensed radiation programs. The inspection procedures used by the Program are 

consistent with the inspection guidance outlined in IMC 2800. The review team found that 

inspection reports were generally thorough, complete, consistent, and of high quality, with 

sufficient documentation to ensure that licensees’ performances with respect to health, safety, 

and security were acceptable. All inspection findings were clearly stated, documented in the 

reports, and reviewed by the Supervisor. The documentation supported violations and any 

discussions held with licensees during exit interviews. The review team identified that some 

inspection documents containing sensitive information were not consistently marked. The 

review team discussed this matter with the Supervisor and Program staff and encouraged them 

to evaluate their procedures and policies for marking and handling sensitive information. The 

Program will review and revise its procedure for identifying and marking sensitive information on 

all documents using the NRC’s “Guidance on Screening Criteria for Security-Related Sensitive 

Unclassified Non-Safeguards Information,” issued December 2005. 

The review team determined that the inspection findings were appropriate and prompt, and 

regulatory actions were taken, as necessary. When the Program issues a notice of violation, 

the licensee is required to provide a written corrective action plan within 30 days. All findings 

are reviewed by the Supervisor. 

The review team verified that all of the Program’s radioactive materials inspectors were 

accompanied annually during the review period. The accompaniment reports contained 

sufficient details to document the areas covered during the accompaniments. 

The review team noted that the Program has an adequate supply of survey instruments to 

support their inspection program, as well as to respond to incidents and emergency conditions. 

Appropriate, calibrated survey instruments, such as Geiger-Mueller (GM) meters, scintillation 

detectors, ion chambers, micro-R meters, and a neutron detector, were observed to be 

available. The Program also has portable multi-channel analyzers for field identification of 

radioisotopes. Instruments are calibrated at least annually, or as needed, with sources that 
Minnesota Final Report Page 5 

were traceable to the National Institute of Standards and Technology. The Program uses a 

database to track each instrument, its current location, and its calibration due date. In addition, 

the Program supplies calibrated radiation detection equipment to the Minnesota Department of 

Transportation’s Hazardous Materials Inspectors, the Minnesota Department of Public Safety’s 

Commercial Vehicle Section, and a HAZMAT team. 

Two review team members conducted accompaniments of three of the Program’s inspectors 

during the weeks of August 6 and August 13, 2007. The inspectors were accompanied during 

health, safety, and security inspections of medical therapy, medical private practice, mobile 

medical, and portable gauge licenses. The accompaniments are identified in Appendix C. 

During the accompaniments, all of the inspectors demonstrated appropriate inspection 

techniques and knowledge of the regulations and conducted performance-based inspections. 

The inspectors were well prepared for the inspection and thorough in their audits of the 

licensees’ radiation safety programs. The inspectors conducted interviews with appropriate 

personnel, observed licensed operations, conducted confirmatory measurements, and utilized 

good health physics practices. The inspections were adequate to assess radiological health, 

safety, and security at the facilities. 

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

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

was satisfactory. 

2.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed license reviewers for 

18 specific licenses. 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, security, 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, and consideration of enforcement history, supervisory review as indicated, and 

proper signatures. The casework was checked for retention of necessary documents and 

supporting data.

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

completed during the review period. Licensing actions selected for evaluation included three 

new licenses, two renewals, six amendments (one denied in part), one termination with 

decommissioning, and six financial assurance files. The sampling included the following license 

types: broadscope manufacturing and distribution, portable gauge, fixed gauge, broadscope 

medical, medical institution - no written directive required, medical institution - diagnostic and 

therapy, measuring systems, general license distribution, and gamma knife. 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 thorough, complete, consistent, and of 

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

conditions were stated clearly, backed by information contained in the file, in most cases, and 

auditable. The review team noted some instances where license conditions were not backed by 

information contained in the file. This issue was discussed with Program managers. The 
Minnesota Final Report Page 6 

Program will review and revise its policy for including essential supplemental information in the 

license file. 

Licenses and correspondence are generated using standardized conditions and formats. 

Licensing staff appropriately used the Program’s licensing guides, policies, and standard license 

conditions. The license evaluators use checklists that generally follow the NRC’s NUREG-1556, 

“Consolidated Guidance About Materials Licenses,” to assist in the reviews. Licensees’ 

compliance histories were taken into account when reviewing all renewal applications and major 

amendments. 

Licenses are issued for a 5-year period under a timely renewal system. Each licensing action is 

given a technical peer review by a fellow license evaluator using a multi-phase process. The 

Supervisor performs a second technical review and signs the license. In addition, the 

Environmental Health Manager, who oversees the Section, also reviews and signs the license. 

The Program is planning to move to a system where the license will be signed by the preparing 

license evaluator, the peer-reviewing license evaluator, and the Supervisor. 

The Program’s policy for license issuance includes the requirement for all licenses to be sent by 

certified mail with return receipt requested. The review team believes that this practice, if used 

for licenses containing sensitive unclassified, non-safeguards information (SUNSI), would place 

additional control on SUNSI documents that contain information that could be used for 

malevolent purposes. This method would ensure that the license document is received by the 

correct licensed facility and to the appropriate addressee. First class mail does not provide that 

protection of sensitive information. The review team recommended, and the MRB agreed, that 

the Program’s policy of sending licenses by certified mail with return receipt requested be 

identified as a good practice. 

Terminated licensing actions were well documented, showing appropriate radioactive material 

transfer and survey records. Confirmatory surveys were conducted, when appropriate. The 

review team evaluated financial assurance documents and decommissioning activities 

conducted by the Program, and identified some cases of missing documents or missing 

statements in the financial assurance records. The Program was not familiar with certain 

aspects of the requirements of each of the financial instruments. This was discussed with the 

Program manager who will review and revise their procedure for financial assurance 

requirements using the guidance found in NRC’s NUREG-1757, Volume 3, “Consolidated 

Decommissioning Guidance – Financial Assurance, Recordkeeping, and Timeliness – Final 

Report.” 

The Program kept good track of the progress of licensing actions from receipt of request to 

issuance of license, paying attention to timeliness in processing. The review team found that 

some documents in the licensing files and some outgoing documents to licensees (i.e., cover 

letters and licenses) containing sensitive information were not marked or identified. This issue 

was previously mentioned from the inspection standpoint in Section 2.3 of this report and was 

also discussed with Program managers. 

The review team noted that the Program has a procedure for doing pre-licensing visits. To date, 

the Program has only performed one pre-licensing visit on a naturally occurring or acceleratorproduced radioactive material license. 
Minnesota Final Report Page 7 

The review team examined the list of licensees that the Program determined to meet the criteria 

for the Increased Controls, per COMSECY-05-0028, “Staff Response to SRM for COMSECY05-0015: Initiatives for Increasing Agreement State Participation in the Control of Sources.” 

The review team determined that the Program had correctly identified the licensees that require 

the Increased Controls based on these criteria. The Program also required their licensees 

currently under an NRC Order for additional security measures to implement the Increased 

Controls. Each licensee was issued a license amendment, requiring the Increased Controls, in 

accordance with the time lines established by the NRC in the Staff Requirements Memorandum 

for COMSECY-05-0028. 

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

that Minnesota’s performance with respect to the indicator, Technical Quality of Licensing 

Actions, was satisfactory. 

2.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Program’s actions in responding to incidents and 

allegations, the review team examined the Program’s response to the questionnaire relative to 

this indicator, evaluated selected incidents reported for Minnesota in the Nuclear Material 

Events Database (NMED) against those contained in the Program’s files, and evaluated the 

casework for 11 radioactive materials incidents. A listing of the casework examined can be 

found in Appendix E. The review team also evaluated the Program’s response to two 

allegations, involving radioactive materials, referred to the State by the NRC during the review 

period. 

The incidents selected for review included lost radioactive material and damaged equipment. 

The review team determined that the Program’s response to incidents was complete and 

comprehensive. Initial responses were prompt and well coordinated, and the level of effort was 

commensurate with the health and safety significance. When notified of an incident, the 

Supervisor and staff decided on the appropriate level of initial response. The Program 

dispatched inspectors for on-site investigations in appropriate situations and took suitable 

enforcement and follow up actions when necessary. 

The review team identified 11 byproduct material incidents in NMED for Minnesota during the 

review period, of which seven required reporting. The review team evaluated the Program’s 

timeliness in reporting incidents to the NRC Headquarters Operations Center, and determined 

that, following notification from the licensee, the Program reported all incidents within the 

required time frame. Program staff members incorporated incident information into their 

incident database and provided that information electronically to the NRC’s contractor 

responsible for maintaining NMED. The database was updated as needed. The review team 

found that incident information in NMED for Minnesota incidents was up to date and complete. 

In evaluating the effectiveness of the State's response to allegations, the review team evaluated 

the casework for two allegations referred to the State by the NRC during the review period. The 

review team concluded that the Program took prompt and appropriate action in response to all 

concerns raised. Both of the allegations were appropriately closed, and affected individuals 

were notified of the actions taken. The State adequately protected the identity of concerned 

individuals. 
Minnesota Final Report Page 8 

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

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

Allegation Activities, was satisfactory. 

3.0 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. Minnesota’s Agreement with the NRC does not relinquish authority for a Sealed 

Source and Device Evaluation Program, a Low-Level Radioactive Waste Disposal Program, or 

a Uranium Recovery Program; therefore, only the first non-common performance indicator was 

applicable to this review. 

3.1 Compatibility Requirements

3.1.1 Legislation

Minnesota became the 34th Agreement State on March 31, 2006. The current effective statutory 

authority is contained in the Minnesota Statutes, Sections 144.12 through 144.1205. Section 

144.1202 authorized the Governor to enter into the Agreement with the NRC and contains 

provisions for the orderly transfer of regulatory authority over affected licenses from NRC to the 

State. This Section also identifies the Minnesota Department of Health as the lead agency for 

the Agreement State program. In addition to their response to the questionnaire, the Program 

provided the review team with the opportunity to review copies of legislation that affects the 

radiation control program. 

3.1.2 Program Elements Required for Compatibility

The State’s regulations for control of radiation are located in the Minnesota Rules Chapter 4731

and apply to all ionizing radiation, whether emitted from a radionuclide or device. Minnesota 

requires a license for possession and use of all radioactive materials, including naturally 

occurring radioactive materials, such as radium, and accelerator-produced radionuclides. 

The review team examined the State’s administrative rulemaking process and found that the 

process typically takes approximately 1 year after drafting before a rule becomes effective. 

Draft rules are developed by Program staff and then sent to the Office of the Revisor of 

Statutes. Proposed rules are then published for comment in a Notice of Intent to Adopt Rules in 

the Minnesota Register. A hearing opportunity is offered upon publication of the notice. An 

Administrative Law Judge approves final rules prior to submission to the Secretary of State for 

final approval. At the conclusion of the rulemaking process, a Notice of Adoption is published in 

the Minnesota Register. The Governor’s office is informed of proposed rules at each step in the 

process. The State has the authority to issue legally-binding requirements (e.g., license 

conditions) in lieu of regulations until compatible regulations become effective. Minnesota’s 

regulations are not subject to any sunset provisions. 

The review team evaluated the Program’s response to the questionnaire relative to this 

indicator, reviewed the status of regulations required to be adopted by the State under the 

NRC’s adequacy and compatibility policy, and verified the adoption of regulations with data 
Minnesota Final Report Page 9 

obtained from the Office of Federal and State Materials and Environmental Management 

Programs’ State Regulation Status Sheet. 

Current NRC policy requires that Agreement States adopt certain equivalent regulations or 

legally-binding requirements no later than three years after they become effective. The review 

team identified the following regulation as overdue for adoption at the time of the review. 

Minnesota’s addressed this amendment in a rulemaking package that became effective on 

November 20, 2007. 

● “Financial Assurance for Materials Licensees,” 10 CFR Part 30, 40, 70 amendments (68 FR 

57327) that became effective December 3, 2003, and was due for Agreement State 

adoption by December 3, 2006. 

The State uses legally-binding requirements, in the form of license conditions, to address the 

following four regulations. All are part of the current rulemaking package discussed above. The 

review team sampled the State’s licenses to ensure that license conditions were used 

appropriately. 

● "Compatibility with IAEA Transportation Safety Standards and Other Transportation Safety 

Amendments," 10 CFR Part 71 amendment (69 FR 3697) that became effective on 

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

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

30 amendment (70 FR 2001), that became effective on July 11, 2005, and is due for 

Agreement State adoption by July 11, 2008. 

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

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

due for Agreement State adoption by April 29, 2008. 

● “Minor Amendments,” 10 CFR Part 20, 30, 32, 35, 40 and 70 amendments (71 FR 15005) 

that became effective March 27, 2006, and is due for Agreement State adoption by 

March 27, 2009. 

Based on the IMPEP evaluation criteria, the review team recommends that Minnesota’s 

performance with respect to the indicator, Compatibility Requirements, be found satisfactory. 

4.0 SUMMARY 

As noted in Sections 2.0 and 3.0, Minnesota’s performance was found to be satisfactory for all 

performance indicators reviewed. The review team made no recommendations regarding 

program performance and identified one good practice. Accordingly, the review team 

recommended, and the MRB agreed, that the Minnesota Agreement State Program was 

adequate to protect public health and safety and compatible with NRC's program. Based on the 

results of the current IMPEP review, the review team recommended, and the MRB agreed, that 

the next full IMPEP review take place in approximately 4 years. 
Minnesota Final Report Page 10 

Below is the good practice, as mentioned earlier in the report: 

The Program’s policy for license issuance includes the requirement for all licenses to be sent by 

certified mail with return receipt requested. The review team believes that this practice, if used 

for licenses containing sensitive unclassified, non-safeguards information (SUNSI), would place 

additional control on SUNSI documents that contain information that could be used for 

malevolent purposes. This method would ensure that the license document is received by the 

correct licensed facility and to the appropriate addressee. First class mail does not provide that 

protection of sensitive information. The review team recommended, and the MRB agreed, that 

the Program’s policy of sending licenses by certified mail with return receipt requested be 

identified as a good practice. 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Minnesota Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Attachment December 7, 2007, E-mail from George Johns 

 Minnesota’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Linda McLean, Region IV Team Leader 

 Technical Staffing and Training 

Michelle Beardsley, Region I Status of Materials Inspection Program 

 Technical Quality of Inspections 

Tobias Lickerman, New York Technical Quality of Licensing Actions 

James Lynch, Region III Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

Inspector Accompaniments 

Randy Erickson, Region IV Inspector Accompaniments 
APPENDIX B 

MINNESOTA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML072410053 

PAGES 11-13 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Hennepin County Med. Ctr. License No.: 1164-100-27 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 3/5-6/07 Inspectors: BJ, SF, SM, CV 

File No.: 2 

Licensee: Mayo Clinic License No.: 1047-201-55 

Inspection Type: Special, Announced Priority: 2 

Inspection Dates: 11/16/06 Inspectors: BJ, SF, GJ, CV 

File No.: 3 

Licensee: Pro Source Technology License No.: 1196-100-02 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 5/23/07 Inspector: CV 

File No.: 4 

Licensee: 3M Corporation License No.: 1116-101-62 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Dates: 1/22-24/07 Inspectors: TD, SF, BJ, CV 

File No.: 5 

Licensee: Acuren Inspections License No.: 1191-101-89 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Dates: 10/16-18/07 Inspectors: CV, GJ 

File No.: 6 

Licensee: Immanuel St. Joseph’s License No.: 1025-200-07 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 12/19/06 Inspectors: SF, GJ, CV 

File No.: 7 

Licensee: Shared Medical Technologies License No.: 1041-201-89 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Dates: 4/18-19/07 Inspector: SF 

File No.: 8 

Licensee: Immanuel St. Joseph’s License No.: 1025-200-07 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 6/26/07 Inspectors: SM, GJ 
Minnesota Final Report Page C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: St. Francis Regional Med. Ctr. License No.: 1064-200-70 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/29/07 Inspectors: BJ, SF 

File No.: 10 

Licensee: Braun Intertec License No.: 1082-100-27 

Inspection Type: Routine, Announced Priority: 1 

Inspection Dates: 8/8-9/07 Inspector: BJ 

File No.: 11 

Licensee: Braun Intertec License No.: 1082-100-27 

Inspection Type: Special, Announced Priority: 1 

Inspection Dates: 8/8-9/07 Inspector: BJ 

Comment: 

Cover letter was not marked as containing sensitive information although the attached 

notice of violation was appropriately marked as sensitive. 

File No.: 12 

Licensee: Midwest Industrial X-Ray License No.: 1186-101-89 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Dates: 6/21 & 7/12/07 Inspectors: CV, SM 

File No.: 13 

Licensee: Midwest Industrial X-Ray License No.: 1186-101-89 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 9/6/06 Inspectors: CV, SM 

File No.: 14 

Licensee: Mallinckrodt, Inc. License No.: 1023-201-89 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 8/7/07 Inspectors: SF, GJ 

File No.: 15 

Licensee: Alpha Omega Services License No.: 9039-100-00 

Inspection Type: Reciprocity, Special, Announced Priority: N/A 

Inspection Date: 9/17/07 Inspector: CV 

Comment: 

Inspection report contained sensitive information but was not marked appropriately. 

File No.: 16 

Licensee: Parker Hughes License No.: 1176-101-62 

Inspection Type: Decommissioning-Special, Announced Priority: N/A 

Inspection Date: 8/15/06 Inspector: SF 
Minnesota Final Report Page C.3 

Inspection Casework Reviews 

File No.: 17 

Licensee: Varian Medical Systems License No.: 9013-101-00 

Inspection Type: Reciprocity, Special, Announced Priority: N/A 

Inspection Date: 8/16/07 Inspector: CV 

File No.: 18 

Licensee: Minneapolis Radiation Oncology License No.: 1162-101-27 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 8/17-28/07 Inspector: SF 

File No.: 19 

Licensee: Memorial Blood Centers License No.: 1084-101-27 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 8/1/07 Inspector: BJ 

File No.: 20 

Licensee: Memorial Blood Centers License No.: 1084-101-27 

Inspection Type: Special, Announced Priority: 5 

Inspection Date: 8/1/07 Inspector: BJ 

Comment: 

Inspection report contained sensitive information but was not marked appropriately. 

File No.: 21 

Licensee: Philotechnics License No.: 9032-100-00 

Inspection Type: Reciprocity-Special, Unannounced Priority: N/A 

Inspection Date: 6/19/07 Inspector: BJ 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Medical Diagnostics License No.: 1031-201-62 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 8/6/07 Inspector: BJ 

Accompaniment No.: 2 

Licensee: Mobile Imaging Services License No.: 1198-100-27 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 8/7/07 Inspector: CV 

Accompaniment No.: 3 

Licensee: Braun Intertec Corp. License No.: 1082-100-27 

Inspection Type: Routine/Special, Announced Priority: 1 

Inspection Date: 8/8/07 Inspector: BJ 
Minnesota Final Report Page C.4 

Inspection Casework Reviews 

Accompaniment No.: 4 

Licensee: Minneapolis Radiation Oncology License No.: 1162-101-27 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/17/07 Inspector: SF 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Health East St. John’s Hospital License No.: 1033-202-62 

Type of Action: Amendment (denied in part) Amendment No.: 02 

Date Issued: 7/31/07 License Reviewer: CV 

File No.: 2 

Licensee: Mayo Clinic License No.: 1047-201-55 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 10/26/06 License Reviewer: SF 

File No.: 3 

Licensee: Acuren Inspection, Inc. License No.: 1191-102-89 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 4/16/07 License Reviewer: CV 

File No.: 4 

Licensee: Global Medical Instrumentation License No.: 1102-100-62 

Type of Action: New Amendment No.: 00 

Date Issued: 10/8/07 License Reviewer: SF 

File No.: 5 

Licensee: Pro Source Technologies License No.: 1196-100-02 

Type of Action: New Amendment No.: 00 

Date Issued: 7/6/06 License Reviewer: BJ 

File No.: 6 

Licensee: St. Mary’s Hospital License No.: 1077-103-55 

Type of Action: Amendment Amendment No.: 03 

Date Issued: 9/17/07 License Reviewer: CV 

File No.: 7 

Licensee: Immanuel St. Joseph’s License No.: 1025-200-07 

Type of Action: Renewal Amendment No.: 00 

Date Issued: 3/27/06 License Reviewer: SF 

File No.: 8 

Licensee: Mobile Imaging Service License No.: 1198-100-27 

Type of Action: New Amendment No.: 00 

Date Issued: 4/2/07 License Reviewer: CV 
Minnesota Final Report Page D.2 

License Casework Reviews 

File No.: 9 

Licensee: Parker Hughes Institute License No.: 1176-101-62 

Type of Action: Termination with Decommissioning Amendment No.: 01 

Date Issued: 8/18/06 License Reviewer: SF 

File No.: 10 

Licensee: Medtronic, Inc. License No.: 1166-102-27 

Type of Action: Amendment Amendment No.: 02 

Date Issued: Pending License Reviewer: SF 

File No.: 11 

Licensee: 3M Corporate Health Physics Services License No.: 1116-101-62 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 2/12/07 License Reviewer: CV 

File No.: 12 

Licensee: 3M Company License No.: 1066-200-62 

Type of Action: Renewal Amendment No.: 00 

Date Issued: Pending License Reviewer: SF 

File No.: 13 

Licensee: Hennepin County Medical Center License No.: 1164-100-27 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 6/23/06 License Reviewer: GJ 

File No.: 14 

Licensee: Detector Electronics Corp. License No.: 1150-100-27 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 4/4/06 License Reviewer: GJ 

Comment: 

 Original letter of credit was not in the file. 

File No.: 15 

Licensee: U.S. Steel License No.: 1081-102-69 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 7/31/06 License Reviewer: GJ 

File No.: 16 

Licensee: 3M Corporation License No.: 1066-100-62 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 3/31/06 License Reviewer: GJ 
Minnesota Final Report Page D.3 

License Casework Reviews 

File No.: 17 

Licensee: University of Minnesota License No.: 1049-200-27 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 5/25/06 License Reviewer: GJ 

Comment: 

 Statement of intent does not contain dollar amount of financial assurance. 

File No.: 18 

Licensee: Mayo Clinic License No.: 1047-200-55 

Type of Action: Financial Assurance Amendment No.: N/A 

Date Issued: 4/13/06 License Reviewer: GJ 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Mayo Clinic License No.: 1047-201-55 

Date of Incident: 12/6/06 NMED Log No.: 070179 

Investigation Date: 1/10/07 Type of Incident: Lost Source 

Type of Investigation: Telephone 

File No.: 2 

Licensee: 3M Company License No.: 1066-100-62 

Date of Incident: 9/5/06 NMED Log No.: 060638 

Investigation Date: 9/7/06 Type of Incident: Lost Source 

Type of Investigation: Site 

File No.: 3 

Licensee: Sappi Fine Paper North America License No.: 1112-102-09 

Date of Incident: 10/18/06 NMED Log No.: 070178 

Investigation Date: 11/9/06 Type of Incident: Damaged Gauge 

Type of Investigation: Telephone 

File No.: 4 

Licensee: American Engineering Testing, Inc. License No.: 1090-102-62 

Date of Incident: 9/9/07 NMED Log No.: 070572 

Investigation Date: 9/10/07 Type of Incident: Damaged Gauge 

Type of Investigation: Site 

File No.: 5 

Licensee: 3M Corporate License No.: 1116-101-62 

Date of Incident: 7/1/06 NMED Log No.: 060752 

Investigation Date: 12/7/06 Type of Incident: Lost Source 

Type of Investigation: Telephone 

File No.: 6 

Licensee: University of Minnesota Fairview Riverside License No.: 1035-200-37 

Date of Incident: 6/30/06 NMED Log No.: 060428 

Investigation Date: 7/28/06 Type of Incident: Lost Sources 

Type of Investigation: Telephone 
Minnesota Final Report Page E.2 

Incident Casework Reviews 

File No.: 7 

Licensee: Immanuel St. Joseph’s License No.: 1025-200-07 

Date of Incident: 4/24/07 NMED Log No.: 070320 

Investigation Date: 6/26/07 Type of Incident: Lost Source 

Type of Investigation: Site 

File No.: 8 

Licensee: Asset Management, Inc. License No.: 1008-200-82 

Date of Incident: 9/13/07 NMED Log No.: 070578 

Investigation Date: 9/13/07 Type of Incident: Stolen Gauge 

Type of Investigation: Telephone 

File No.: 9 

Licensee: Dayton’s Bluff Neighborhood Services License No.: General License 

Date of Incident: 6/23/06 NMED Log No.: 060421 

Investigation Date: 6/26/06 Type of Incident: Missing Device 

Type of Investigation: Telephone 

File No.: 10 

Licensee: Innovex, Inc. License No.: General License 

Date of Incident: 5/10/07 NMED Log Nos.: 070532 and 070533 

Investigation Date: 5/14/07 Type of Incident: Lost Sources 

Type of Investigation: Site 

File No.: 11 

Licensee: Seagate Technology License No.: General License 

Date of Incident: 10/10/06 NMED Log No.: 060711 

Investigation Date: 11/21/06 Type of Incident: Lost Sources 

Type of Investigation: Site 
ATTACHMENT 

December 7, 2007, E-mail from George Johns 

Minnesota’s Response to Draft IMPEP Report 

ADAMS: ML073470337