January 26, 2009 

Alvin D. Jackson, M.D. 

Director 

Ohio Department of Health 

246 North High Street 

Columbus, OH 43215 

Dear Dr. Jackson: 

On January 14, 2009, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Ohio Agreement 

State Program. The MRB found the Ohio Agreement State Program adequate to protect public 

health and safety and compatible with the U.S. Nuclear Regulatory Commission=s (NRC) 

program. 

Section 5.0, page 13, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendation. Your letter dated December 30, 2008, adequately 

discusses the State’s actions for resolving the review team’s recommendation. No further 

response is requested at this time. Based on the results of the current IMPEP review, the next 

full review of the Ohio Agreement State Program will take place in approximately 4 years, with a 

periodic meeting tentatively scheduled for April 2010. During the periodic meeting and at the 

next IMPEP review, NRC will evaluate the effectiveness of your State’s response to the review 

team’s recommendation, as well as the overall implementation of your Agreement State 

program. 

The MRB recognized that this review was Ohio’s third IMPEP review since becoming an 

Agreement State in 1999 and that it was the third consecutive IMPEP review in which the Ohio 

Agreement State Program was found adequate to protect public health and safety, compatible 

with the NRC’s program, and satisfactory for all performance indicators reviewed. These are 

the highest possible ratings for an IMPEP review. I applaud your staff for their dedication to 

excellence in radiation protection. 
A. Jackson - 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 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: 

Ohio Final IMPEP Report 

cc w/encl: Michele Shipp, M.D., DrPH, 

 Assistant Director 

 Ohio Department of Health 

 Robert E. Owen, Chief 

 Ohio Bureau of Radiation 

 Protection 

 Michael Snee, Administrator 

 Nuclear Material Safety Program 

 Ohio Bureau of Radiation 

 Protection 

 Carol O’Claire, 

 State Liaison Officer 

 Ohio Emergency Management 

 Agency 

 Alice Rogers, Texas 

 Organization of Agreement 

 States Liaison to the MRB 
A. Jackson - 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 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: 

Ohio Final IMPEP Report 

cc w/encl: Michele Shipp, M.D., DrPH, 

 Assistant Director 

 Ohio Department of Health 

 Robert E. Owen, Chief 

 Ohio Bureau of Radiation 

 Protection 

 Michael Snee, Administrator 

 Nuclear Material Safety Program 

 Ohio Bureau of Radiation 

 Protection 

 Carol O’Claire, 

 State Liaison Officer 

 Ohio Emergency Management 

 Agency 

 Alice Rogers, Texas 

 Organization of Agreement 

 States Liaison to the MRB 

DISTRIBUTION: See next page 

 ML090150392 

OFFICE FSME/DMSSA FSME/DMSSA FSME/DMSSA 

NAME ATMcCraw:km AImboden RJLewis 

DATE 01/15/09 01/15/09 01/15/09 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland (PTressler for) CLMiller MJVirgilio 

DATE 01/16/09 01/22/09 01/26/09 

OFFICIAL RECORD COPY
Letter to Alvin D. Jackson, M.D., from Martin J. Virgilio dated: January 26, 2009

DISTRIBUTION: EDATS: FSME-2009-0003 

DMSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Klein 

KLukes, FSME/DMSSA Commissioner Jaczko 

JLynch, RIII/RSAO Commissioner Lyons 

DSollenberger, FSME/DMSSA Commissioner Svinicki 

SHammann, RI SECY 

Joshua Daehler, Massachusetts 

Robert Dansereau, New York 

ARivera, OEDO 

KCyr, OGC 

BJones, OGC 

ECollins, RIV 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE OHIO AGREEMENT STATE PROGRAM 

October 27-31, 2008 

FINAL REPORT
Ohio Final Report Page 1 

1.0 INTRODUCTION 

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

was conducted during the period of October 27-31, 2008, by a review team comprised of 

technical staff members from the U.S. Nuclear Regulatory Commission (NRC), the 

Commonwealth of Massachusetts, and the State 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 NRC 

Management Directive 5.6, “Integrated Materials Performance Evaluation Program (IMPEP),” 

dated February 26, 2004. Preliminary results of the review, which covered the period of 

October 30, 2004, to October 31, 2008, were discussed with Ohio managers on the last day of 

the review. 

A draft of this report was issued to Ohio for factual comment on December 2, 2008. The State 

responded by letter on December 30, 2008, from Dr. Alvin D. Jackson, Director, Department of 

Health (the Department). A copy of the State’s response is included as the Attachment to this 

report. The Management Review Board (MRB) met on January 14, 2009, to consider the 

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

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

The Ohio Agreement State Program is administered by the Bureau of Radiation Protection (the 

Bureau). The Bureau is located within the Department. Organization charts for the Bureau are 

included in Appendix B. 

At the time of the review, the Ohio Agreement State Program regulated 748 specific licenses 

authorizing byproduct, source, and certain special nuclear materials. 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 NRC and the State of Ohio. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Bureau on July 30, 2008. The Bureau 

provided its response to the questionnaire on October 6, 2008. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML083080280. 

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

the Bureau’s response to the questionnaire, (2) review of applicable Ohio statutes and 

regulations, (3) analysis of quantitative information from the Bureau’s database, (4) technical 

review of selected regulatory actions, (5) field accompaniments of six inspectors, and (6) 

interviews with staff and managers. 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 Ohio Agreement State Program’s 

performance. 

Section 2.0 of this report covers the State’s actions in response to recommendations made 

during previous reviews. Results of the current review of the common performance indicators 

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable 
Ohio Final Report Page 2 

non-common performance indicators, and Section 5.0 summarizes the review team's findings 

and recommendations. The review team’s recommendations 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 October 30, 2004, the review team 

made no recommendations regarding program performance. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review 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. 

3.1 Technical Staffing and Training

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

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

this indicator, the review team examined the Bureau’s questionnaire response relative to this 

indicator, interviewed Bureau managers and staff, reviewed job descriptions and training 

records, and considered any possible workload backlogs. 

The Bureau is located in the Department offices in Columbus and is headed by the Bureau 

Chief. The Bureau is divided into three programs: the Nuclear Material Safety Program, the 

X-ray Program, and the Technical Support Program. Each program is managed by an 

administrator. The Agreement State program is implemented by the Nuclear Material Safety 

Program and a portion of the Technical Support Program. The Nuclear Material Safety Program 

functions as the licensing and inspection group for radioactive materials. The Technical Support 

Program is responsible for oversight of the training and quality assurance programs. The 

Bureau expends approximately 20.3 full time equivalents, including vacant positions, to 

implement the Agreement State program. 

The Nuclear Material Safety Program consists of the Medical, the Industrial, and the 

Decommissioning Sections, all of which are managed by section supervisors. The Medical and 

Industrial Sections conduct the routine licensing and inspection of most of the materials 

facilities. The Decommissioning Section conducts license terminations and partial site releases 

and also is responsible for all low-level radioactive waste activities. Technical staff performs 

both inspection and licensing functions. Three staff members from the Industrial and the 

Decommissioning Sections conduct the sealed source and device (SS&D) evaluation program. 

Staffing and training for the SS&D evaluation program is further discussed in Section 4.2.1 of 

this report. 

The technical staff positions are classified as Health Physicist II or III, with Health Physicist III 

being the senior-level technical position. At the time of the review, there were three vacant 

positions in the Agreement State program. Two of these vacant positions were for Health 
Ohio Final Report Page 3 

Physicist II positions in the Medical Section, and the other was for a Health Physicist II in the 

Industrial Section. Bureau management indicated that a plan within the Bureau has been 

established to prioritize each of the vacant positions in order to deal with the challenges in 

receiving the Office of Budget and Management’s approval for filling vacancies. With additional 

resource-intensive security initiatives on the horizon, Bureau management indicated that the 

Agreement State program could be adversely impacted if the vacancies cannot be filled in a 

timely manner. 

The review team noted that the Bureau had stable funding during the review period due to 

dedicated revenue from various fees. In an effort to avoid any future budget shortfalls that could 

result in the inability to fill vacancies, the Bureau considered a 20 percent across-the-board fee 

increase on various licensee fees, but ultimately submitted an 8 percent increase proposal for 

the Office of Budget and Management’s consideration. The Bureau’s last fee increase occurred 

in 2001. 

Using information from the questionnaire, training records, and interviews of personnel, the 

review team determined that the staff is well qualified from an education and experience 

standpoint. All staff members have at least a Bachelor’s degree in the science or equivalent 

training and experience. 

At the previous review, the Bureau had a documented training and qualifications program for 

technical staff that was similar to NRC’s Inspection Manual Chapter (IMC) 1246, “Formal 

Qualification Programs in the Nuclear Materials Safety and Safeguards Area.” Since then, the 

Bureau has evolved its training and qualification program and tracking process to promote a 

more cohesive program across all three sections within the Nuclear Material Safety Program. 

Due to this, the staff training and qualification documentation and policy statement was only 

available for the more senior staff and was not being used for the newer staff. Instead, the 

Bureau relies on each section supervisor to handle the qualification process and determine the 

necessary training for a new employee. The review team recommends that the State document 

and implement a training and qualification program that, at a minimum, contains a statement of 

policy, minimum qualifications for staff training, and supervisory verification for ensuring this 

policy is implemented. 

Following the on-site review, the Bureau developed and submitted a new training and 

qualification program to the review team. The implementation of the new training and 

qualification program should be discussed during the next scheduled periodic meeting and 

evaluated at the next IMPEP review. 

The Bureau uses a combination of self-study; formal training, such as NRC courses; and onthe-job experience to qualify staff as both inspectors and license reviewers. New staff is trained 

in licensing and inspection by performing simple licensing and inspection activities and gradually 

working toward more technical activities. All new staff members perform licensing actions and 

inspections with a senior-level staff member providing support and guidance until they are 

approved by their supervisor to work independently. An individual is approved to perform 

independent actions after the supervisor has observed or reviewed the individual’s performance 

on several licensing actions or inspections of a given license type. The State uses “Ohio Train,” 

a new State-wide web-based system, to electronically track each staff member’s training history. 

This system also assists staff in querying the availability of various in-State, out-of-State, NRC, 
Ohio Final Report Page 4 

and out-of-country training courses. The Bureau is in the process of integrating this system into 

its training and qualification program. The review team noted that Bureau managers support 

training opportunities, based on program needs and funding. 

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

that Ohio’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 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 Bureau’s questionnaire response relative to this indicator, data gathered from the 

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

supervisors and staff. 

The review team’s evaluation of the Bureau’s inspection priorities revealed that inspection 

frequencies for each type of radioactive material license are the same or more frequent than 

similar license types listed in NRC’s IMC 2800, “Materials Inspection Program,” with the 

following three exceptions: Gamma Stereotactic Radiosurgery; Source Material Possession 

Only - Permanent Shutdown; and Special Nuclear Material Possession Only (Non-Fuel) - 

Permanent Shutdown. These categories of license types have inspection priorities less 

frequent than those prescribed by IMC 2800; however, during the review period, the Bureau 

inspected these license types at intervals consistent to those in IMC 2800. The Bureau can only 

change these priority frequencies through rulemaking and plans to change them during the next 

revision to Section 3701:1-38-02 of the Ohio Administrative Code (OAC). 

The Bureau conducted a total of 450 inspections of high priority (Priority 1, 2, and 3) licensees 

during the review period. The review team identified four of these inspections as performed 

overdue by more than 25 percent of the inspection frequency listed in IMC 2800. The review 

team calculated that the Bureau performed less than 1 percent of all Priority 1, 2, and 3 

inspections overdue during the review period. The review team also evaluated the Bureau’s 

timeliness for conducting initial inspections. The review team determined that the Bureau 

conducted 112 initial inspections of new radioactive materials licenses during the review period, 

all of which were inspected within 12 months of license issuance.

The review team evaluated the Bureau’s timeliness of issuance of inspection findings to 

licensees using 24 inspection casework reviews. All inspection findings reviewed were issued 

within 30 days of the inspection date.

During the review period, the Bureau granted 143 reciprocity permits to candidate licensees 

based upon the criteria in NRC’s 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 Bureau inspected 30 percent of the candidate licensees which exceeds the criterion in 

IMC 1220 that requires on-site inspection of at least 20 percent of candidate licensees operating 

under reciprocity.
Ohio Final Report Page 5 

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

Controls inspections of affected licensees. The Bureau identified 51 licensees met the criteria 

for the Increased Controls. The review team evaluated the Bureau’s prioritization methodology 

and found it acceptable. During the review period, the Bureau performed 66 Increased Controls 

inspections. The Bureau is conducting subsequent Increased Controls inspections at the same 

time as routine health and safety inspections for affected licensees. The review team 

determined that the inspectors are reviewing the pertinent aspects of the security measures 

during the subsequent inspections. 

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

that Ohio’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, inspection field 

notes, and interviewed the responsible inspectors for 24 radioactive materials inspections 

conducted during the review period. The casework reviewed included inspections conducted by 

10 of the Bureau’s inspectors and covered inspections of various license types including: 

academic, manufacturing and distribution, medical, and research and development 

broadscopes; medical institutions; medical private practice; industrial radiography; irradiator; 

veterinary; high dose-rate remote afterloader; nuclear pharmacy; decommissioning; Increased 

Controls; and reciprocity. Appendix C lists the inspection casework files reviewed. 

The review team found that inspection reports were generally thorough, complete, consistent, 

and of high quality, with sufficient documentation to ensure that a licensee’s performance with 

respect to health, safety, and security was acceptable. The Bureau’s inspection procedures are 

generally consistent with the inspection guidance outlined in IMC 2800 and other NRC 

inspection procedures. 

All inspection findings were clearly stated and documented in the inspection report and 

reviewed by the appropriate section supervisor and the Program Administrator before being 

sent to the licensee. Inspection findings led to appropriate and prompt regulatory action, when 

necessary. Escalated enforcement actions were reviewed and sent from either the Bureau 

Chief or the Department Director, depending upon the situation. 

The review team determined that documents involving Increased Controls inspections were 

protected and maintained in a locked file cabinet with limited access. The review team 

determined that documents were sufficiently marked as sensitive information to be withheld 

from public disclosure. 

Supervisory accompaniments were generally conducted annually for all inspectors. The 

supervisors made a total of 68 documented accompaniments during the review period. One 

inspector had only one documented supervisory accompaniment during the review period. The 

Decommissioning Section Supervisor confirmed that the annual accompaniments were 

performed for this inspector, but were not documented. The review team found that inspectors 

received verbal feedback from the supervisor at the time of the accompaniments. 
Ohio Final Report Page 6 

The review team observed that the Bureau maintains an adequate supply of radiation survey 

instruments to support their inspection and incident response programs. A staff member in the 

Technical Support Program is responsible for sending the survey instruments to the Ohio 

Emergency Management Agency for calibration and/or repair, as needed; however, certain 

instruments are sent to the manufacturer for calibration. The Department’s laboratories perform 

sample radioanalysis for the Bureau, as needed. 

The review team accompanied six Bureau inspectors during the week of September 29, 2008, 

at a medical institution, a nuclear pharmacy, an irradiator, a gamma knife, a high dose-rate 

remote afterloader, and industrial radiography. Appendix C lists the accompaniments. During 

the accompaniments, all of the inspectors demonstrated appropriate performance-based 

inspection techniques and knowledge of the regulations. The inspectors were trained, wellprepared, and thorough in their audits of the licensees’ radiation safety and security programs. 

The inspectors conducted interviews with appropriate personnel, observed licensed operations, 

conducted confirmatory measurements, and utilized good health physics practices. The review 

team determined that the inspections were adequate to assess radiological health, safety, and 

security at the licensed facilities. 

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

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

satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team evaluated the licensing process, examined licensing casework for 22 specific 

licenses, and interviewed staff. Licensing actions were reviewed for completeness, consistency, 

proper possession authorizations, qualifications of authorized users, adequacy of facilities and 

equipment, adherence to good health physics practices, financial assurance, operating and 

emergency procedures, appropriateness of license conditions, and overall quality. The 

casework files were also reviewed for timeliness, use of appropriate correspondence, reference 

to appropriate regulations, supporting documentation, consideration of enforcement history, prelicensing screening, peer/supervisory review, and proper signatures. 

The licensing casework selected provided a representative sample of licensing actions 

completed during the review period, as well as one case of an on-going license 

decommissioning and termination. Files reviewed included a cross-section of license types, 

including: medical broadscope (with gamma knife), medical institution, medical private practice, 

nuclear pharmacy, veterinary, industrial radiography, portable and fixed gauge, self-shielded 

irradiator, mobile therapy, academic, broad manufacturing and distribution, and a new and 

emerging technology. Licensing actions selected for evaluation included 4 renewals, 2 new 

licenses, 12 amendments, 1 amendment/renewal, 1 waiver, 1 termination, and 1 pending 

termination. A listing of the licensing casework reviewed can be found in Appendix D. 

The Bureau’s licensing responsibilities are split between the three sections. The Medical 

Section is responsible for all medical use licenses. The Industrial Section is responsible for the 

remaining license types, including those that permit the supply of medical isotopes. The 

Decommissioning Section handles all license terminations as well as closeout of rooms/areas, 
Ohio Final Report Page 7 

and reviews of financial assurance requirements. Incoming licensing actions are directed to the 

appropriate section. The status of all licensing actions is tracked in the Bureau’s interactive 

web-based database. 

The review team determined that the Bureau’s licensing guidance is based on NRC’s NUREG1556 series guides. Reviewers utilize checklists to ensure thorough reviews; however, the 

completed checklists are not required to be retained after the licensing action has been 

completed. 

Each Section generates licenses and correspondence with standardized license templates and 

cover letters. Licensing actions are reviewed by the applicable section supervisor prior to 

signature. Licensing actions for broadscope, industrial radiography, irradiators, Increased 

Controls, complex actions, new technologies, and non-routine items are also reviewed by the 

Nuclear Material Safety Program Administrator. All licensing actions are signed by the Bureau 

Chief. 

The review team evaluated the Bureau’s application of the State’s financial assurance 

requirements. The review team found that the Bureau appropriately requires certain licensees 

to maintain financial assurance for decommissioning. Surety instruments were appropriately 

maintained in a locked cabinet in the secure license file room. The Industrial Section Supervisor 

is responsible for control of the documents. 

Overall, the review team found that, in general, the licensing actions were thorough, complete, 

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

conditions were clearly stated, backed by information in the file, and inspectable. Deficiency 

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

deficiencies appropriately. A complete renewal is due every 5 years. There were no renewal 

actions pending for greater than 1 year. 

The review team examined the Bureau’s licensing practices regarding the Increased Controls 

and Fingerprinting requirements. The review team noted that the Bureau added legally binding 

license conditions to the licenses that met the criteria for implementing the Increased Controls, 

including fingerprinting, as appropriate. The review team analyzed the Bureau’s methodology 

for identifying those licenses and found the rationale was thorough and accurate. The Bureau 

uses NRC’s license screening checklist to identify new applicants that should be subject to the 

Increased Controls. Increased Controls license documents were complete and are maintained 

in separate files in a secured location. 

The Bureau performs pre-licensing checks of all new applicants to verify their identity and need 

for radioactive materials. The Bureau’s method incorporates the essential elements of NRC’s 

pre-licensing guidance. The review team found that, not only did the Bureau apply the prelicense screening guidance for new applicants, the Bureau also applied the pre-license 

screening guidance when an existing licensee applied for an amendment or renewal. 

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

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

was satisfactory. 
Ohio Final Report Page 8 

3.5 Technical Quality of Incident and Allegation Activities

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

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

selected incidents reported for Ohio in the Nuclear Material Events Database (NMED) against 

those contained in the Bureau’s files, and evaluated the casework for 16 of 33 reported 

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

comments, can be found in Appendix E. The review team also reviewed the Bureau’s incident 

files to determine if there were any other reportable incidents that were not appropriately 

reported. The review team also evaluated the Bureau’s response to 5 allegations involving 

radioactive materials reported directly to the State during the review period and 10 allegations 

that NRC referred to the State during the review period. 

When notified of an incident, the Bureau managers and staff discuss the initial response and the 

need for an on-site investigation. The Bureau maintains a database for tracking the status of all 

incidents. If the incident meets the reporting thresholds, as established in NRC’s Office of 

Federal and State Materials and Environmental Management Programs (FSME) Procedure 

SA-300, “Reporting Material Events,” the Nuclear Material Safety Program promptly notifies the 

NRC Headquarters Operations Center, typically by e-mail, using the information template 

established for entering events into NMED. If the investigation is complex and extends over a 

period of time, NMED is appropriately updated, using the established template. Of the incidents 

evaluated by the review team, three were reported late, all of which were self identified 

oversights by the Bureau. 

The incidents selected for review included both medical and industrial events involving lost or 

stolen radioactive material, overexposures, damaged equipment, contamination events, a 

release of radioactive material, and equipment failures. The review team determined that the 

Bureau’s responses to incidents were thorough, complete, and comprehensive. Initial 

responses were prompt and well coordinated, and the level of effort was commensurate with the 

health and safety significance. The Bureau immediately dispatched inspectors to the site when 

the possibility of an immediate threat to public health and safety existed. When no immediate 

threat was present and the Bureau determined that the licensee had qualified, competent 

individuals investigating the incident, the Bureau generally responded telephonically with an onsite followup at a later date. 

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

evaluated the casework for 15 allegations, 10 of which NRC referred to the State. The review 

team concluded that the Bureau consistently took prompt and appropriate action in response to 

the concerns raised. The review team noted that the Bureau thoroughly documented the 

investigations and retained all necessary documentation to appropriately close the allegations. 

The Bureau notified the allegers of the conclusion of their investigations when the allegers’ 

identities were known. The review team determined that the Bureau adequately protected the 

identity of allegers. 

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

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

Allegation Activities, was satisfactory. 
Ohio Final Report Page 9 

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. 

4.1 Compatibility Requirements

4.1.1 Legislation

Ohio became the 31st Agreement State in 1999. Legislative authority to create an agency and 

enter into an Agreement with the NRC is granted in Ohio Revised Code, Section 3748.03. The 

Department is designated as the State’s radiation control agency. The Department Director has 

designated the Bureau Chief to administer the Agreement State program for the Department. 

The review team noted that no new legislation affecting the Agreement State program or its 

authority was passed since the last review, which would affect the Agreement State program or 

its authority. 

4.1.2 Program Elements Required for Compatibility

The Ohio Regulations for Control of Radiation are found in various chapters of Section 3701 of 

the OAC. These rules apply to all ionizing radiation, whether emitted from radionuclides or 

machine sources. Ohio requires a license for possession and use of all radioactive material. 

These rules are subject to review every 5 years to decide whether to continue the rule as it 

exists or modify it. 

The review team examined the procedures used in the Department’s regulatory process and 

found that regulations are drafted by staff and presented to the Radiation Advisory Council (the 

Council). The regulations are posted on the Department’s web site and electronically sent to 

interested stakeholders for a 30- to 45-day comment period. Concurrently, the proposed rules 

are sent to NRC for a compatibility review. Any comments received from NRC, stakeholders, or 

the public are evaluated, and the regulations are revised, as necessary. The revised 

regulations are submitted to the Council for a recommendation for adoption. The formal rule 

adoption process begins with submittal to the Public Health Council, which places the review of 

the proposed rules on their calendar, holds a public hearing, and then submits the proposed 

rules to the Joint Committee on Agency Rules Review (JCARR). JCARR is composed of State 

legislators and senators. After JCARR completes its review of the proposed rules and if it takes 

no action against the rule, the Public Health Council enacts the rule. The rule becomes final 

after it is filed with several State rule codification agencies. The minimum amount of time for a 

rule to become final is approximately 7-10 days after such filing. 

The review team evaluated the Bureau’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 State Regulation Status sheet that FSME maintains. 
Ohio Final Report Page 10 

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

legally binding requirements no later than 3 years after they become effective. The following 

two amendments are overdue, both significantly longer than 3 years from their effective date. 

The current status for each amendment is included: 

• “Medical Administration of Radiation and Radioactive Materials,” 10 CFR Parts 20 and 

35 amendment (60 FR 48623), that was due for Agreement State implementation on 

October 20, 1998. 

Status: The State’s adoption of the overdue amendment “Medical Use of Byproduct 

Material – Recognition of Specialty Boards – Part 35,” will supercede this amendment. 

• “Medical Use of Byproduct Materials - Recognition of Specialty Boards - Part 35,” 

10 CFR Part 35 amendment (70 FR 16336 and 71 FR 1926), that was due for 

Agreement State implementation on April 29, 2008. 

Status: Amendment was approved by the Public Health Council during its December 11, 

2008 meeting. The rule became effective on December 22, 2008, and the final 

amendment will be submitted for NRC review. 

The review team identified the following NRC amendments that the State will need to address in 

the future. The Nuclear Material Safety Program Administrator noted that the amendments 

would be addressed in upcoming rulemakings or through the adoption of legally binding 

requirements: 

● “Minor Amendments,” 10 CFR Parts 20, 30, 32, 35, 40, and 70 amendment (71 FR 

15005), that is due for Agreement State adoption by March 27, 2009. 

Status: Amendment was approved by the Public Health Council during its December 11, 

2008 meeting. The rule became effective on December 22, 2008, and the final 

amendment will be submitted for NRC review. 

● “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 CFR 

Parts 32 and 35 amendment (72 FR 45147 and 72 FR 54207), that is due for Agreement 

State adoption by October 29, 2010. 

Status: Amendment was approved by the Public Health Council during its December 11, 

2008 meeting. The rule became effective on December 22, 2008, and the final 

amendment will be submitted for NRC review. 

● “Requirements for Expanded Definition of Byproduct Material,” 10 CFR Parts 20, 30, 31, 

32, 33, 35, 61, and 150 amendment (72 FR 55864), that is due for Agreement State 

adoption by November 30, 2010. 

Status: Amendment has not been drafted yet. 
Ohio Final Report Page 11 

● “Exemptions from Licensing, General Licenses, and Distribution of Byproduct Material: 

Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32, and 150 amendment 

(72 FR 58473), that is due for Agreement State adoption by December 17, 2010. 

 Status: Amendment was drafted and sent for public and NRC comment. The 

amendment will be submitted to the Council at its next meeting. 

● “Occupational Dose Records, Labeling Containers, and Total Effective Dose Equivalent,” 

10 CFR Parts 19 and 20 amendment (72 FR 68043), that is due for Agreement State 

adoption by February 15, 2011. 

Status: Amendment was drafted and sent for public and NRC comment. The 

amendment will be submitted to the Council at its next meeting. 

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

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

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

In reviewing this indicator, the review team used three subelements to evaluate the Bureau’s 

performance regarding the SS&D Evaluation Program. These subelements were: (1) Technical 

Staffing and Training, (2) Technical Quality of the Product Evaluation Program, and (3) 

Evaluation of Defects and Incidents Regarding SS&Ds. 

In assessing the Bureau’s SS&D evaluation activities, the review team examined information 

contained in the Bureau’s response to the questionnaire for this indicator, performed a search of 

the national SS&D Registry for registrations issued by the Bureau, and performed NMED 

searches of manufacturers and distributors identified on SS&D registrations issued by the 

Bureau. The review team examined inactivated, new, and amended SS&D evaluations and 

supporting documents covering the review period. The review team noted the staff’s use of 

guidance documents and procedures, interviewed managers and staff, and verified the use of 

regulations, license conditions, and inspections to enforce commitments made in the 

applications. 

4.2.1 Technical Staffing and Training

The Bureau has three qualified SS&D reviewers with full signature authority. There were no 

newly qualified SS&D reviewers nor did any qualified SS&D reviewers leave the Bureau during 

the review period. 

The Bureau’s three qualified reviewers each have a degree in engineering, science, or 

equivalent training and experience and have attended NRC’s SS&D workshop. The Bureau 

maintains reviewer qualifications in SS&D Qualification Journals. The review team interviewed 

staff members involved in the reviews and determined that they were familiar with the 

procedures used in the evaluation of devices and sources and had access to applicable 

reference documents. 
Ohio Final Report Page 12 

4.2.2 Technical Quality of the Product Evaluation Program

The review team evaluated 11 of the 30 SS&D actions that the Bureau processed during the 

review period. The actions reviewed were for five new, five amended, and one inactivated 

SS&D registrations. The casework reviewed represented the efforts of all three SS&D 

reviewers. The casework review included all supporting documentation, licenses, and 

inspections associated with the distributors of the SS&Ds. A list of SS&D casework examined 

can be found in Appendix F. 

Analysis of the casework and interviews with the managers and staff confirmed that the 

Bureau’s policy is to follow the recommended guidance from the NRC’s SS&D Workshop and 

the Bureau’s SS&D Evaluation and Registration procedure, NMS-LIC-03, which is equivalent to 

NRC’s NUREG-1556, Volume 3, Revision 1, “Consolidated Guidance About Materials 

Licenses – Applications for Sealed Source and Device Evaluation and Registration.” 

Appropriate review checklists were used to ensure that all relevant materials were submitted 

and evaluated. The checklists were retained in the SS&D files along with other documents that 

identified the responsible reviewers. The review team confirmed that pertinent American 

National Standards Institute standards, NRC Regulatory Guides, and applicable references 

were available and used appropriately in performing the SS&D reviews. 

The registration files contained all correspondence, engineering drawings, photographs, 

radiation profiles, and details of the licensees’ quality assurance and quality control programs. 

The registrations clearly summarized the product evaluations to provide license reviewers with 

adequate information to license the possession and use of the products. Deficiency letters 

clearly stated regulatory positions. The review team determined that the evaluations were of 

high quality with health and safety issues properly addressed. The Bureau enforces the 

requirements of SS&D registrations through conditions made part of specific licenses issued to 

the distributors of SS&D products. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

Based upon the Bureau’s response to the questionnaire, interviews with the Bureau’s managers 

and staff, and the review team’s searches of NMED, the review team determined that there was 

one incident or defect that the Bureau reported during the review period that involved an SS&D 

product registered in Ohio. The report was made for a leaking sealed source. The review team 

determined that the Bureau analyzed the event, reviewed the issues, and followed up on the 

incident adequately and in accordance with procedures established by the Bureau in NMS-LIC03, which includes generic fault considerations when evaluating SS&D incidents. The Bureau 

concluded that the leaking source was not a generic defect. The review team concluded that 

the Bureau is routinely evaluating the root causes of defects and incidents involving SS&D 

evaluations and is taking appropriate actions. 

In addition to the one incident of a leaking sealed source reported by the Bureau, the review 

team discovered 21 equipment failures reported in NMED from other States and NRC that 

involved SS&D products registered in Ohio. The review team compared these reports with any 

action taken by the Bureau. One report involved another leaking sealed source registered in 

Ohio attributed to the same licensee of the Bureau as that for the leaking source reported by the 

Bureau. The other 20 reports involved fixed gauge devices registered in Ohio attributed to a 
Ohio Final Report Page 13 

different licensee of the Bureau. The Bureau made a site visit to its licensee associated with the 

reported equipment failures of fixed gauge devices to identify and document possible root 

causes of the failures and any appropriate actions. The Bureau determined that additional 

information was necessary and scheduled another site visit. 

The review team noted that the Bureau routinely monitors incidents reported to NRC and to 

NMED and identified incidents or defects associated with SS&D products registered in Ohio for 

further investigation and review. One State provided information directly to the Bureau about 

three fixed gauge device failures that occurred in the subject State and the review team noted 

that these incidents were being addressed by the Bureau. The review team shared with the 

Bureau all 21 NMED reports of equipment failures discovered by the review team and noted that 

most of the reports had also been identified by the Bureau. The review team concluded that the 

Bureau is routinely evaluating the root causes of defects and incidents involving SS&D 

evaluations and is taking appropriate actions. 

The review team did not identify any allegations received by the Bureau related to defects or 

failures of SS&D products registered in Ohio during the review period. 

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

that Ohio’s performance with respect to the indicator, Sealed Source and Device Evaluation 

Program, was satisfactory. 

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

Although Ohio has LLRW disposal authority, NRC has not required States to have a program for 

licensing a LLRW 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, it is expected to put a regulatory 

program in place that meets the criteria for an adequate and compatible LLRW disposal 

program. There are no plans for a LLRW disposal facility in Ohio. Accordingly, the review team 

did not review this indicator. 

4.4 Uranium Recovery Program 

Although Ohio has authority to regulate uranium recovery activities, NRC has not required 

States to have a program for licensing a uranium recovery facility until such time as the State 

has such a facility. When an Agreement State has been notified or becomes aware of the need 

to regulate a uranium recovery facility, it is expected to put a regulatory program in place that 

meets the criteria for an adequate and compatible uranium recovery program. There are no 

plans for a uranium recovery facility in Ohio. Accordingly, the review team did not review this 

indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Ohio’s performance was found satisfactory for all performance 

indicators reviewed. Accordingly, the review team recommended, and the MRB agreed, that the 

Ohio 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 
Ohio Final Report Page 14 

team recommended, and the MRB agreed, that the next full IMPEP review take place in 

approximately 4 years. 

Below is the recommendation, as mentioned earlier in the report, for evaluation and 

implementation, as appropriate, by the State: 

 The review team recommends that the State document and implement a training and 

qualification program that, at a minimum, contains a statement of policy, minimum 

qualifications for staff training, and supervisory verification for ensuring this policy is 

implemented. (Section 3.1) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Ohio Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source & Device Casework Reviews 

Attachment December 30, 2008 Letter from Alvin D. Jackson 

 Ohio’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Kim Lukes, FSME Team Leader 

 Technical Staffing and Training 

 Compatibility Requirements 

Stephen Hammann, Region I Status of Materials Inspection Program 

 Technical Quality of Inspections 

 Inspector Accompaniments 

Robert Dansereau, NY Technical Quality of Licensing Actions 

Dennis Sollenberger, FSME Technical Quality of Incident and Allegation 

 Activities 

Joshua Daehler, MA Sealed Source and Device Evaluation Program 
APPENDIX B 

OHIO ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML083220013 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Battelle Memorial Institute License No.: 03610250000 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 11/6/07 Inspector: SD 

File No.: 2 

Licensee: Proctor & Gamble License No.: 03610090000 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/19/05 Inspector: KV 

File No.: 3 

Licensee: MetroHealth Medical Center License No.: 02110180045 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 9/3/08 Inspector: MB 

File No.: 4 

Licensee: St. Elizabeth Boardman Health Center License No.: 02120510001 

Inspection Type: Initial, Unannounced Priority: 3 

Inspection Date: 10/1/07 Inspector: LS 

File No.: 5 

Licensee: The Bellevue Hospital License No.: 02120040000 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 7/22/08 Inspector: DC 

File No.: 6 

Licensee: BWX Technologies, Inc. License No.: 03310780006 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/12/07 Inspectors: JR, MR 

File No.: 7 

Licensee: JANX Integrity Group License No.: 03320990002 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 5/12/08 Inspector: MR 

File No.: 8 

Licensee: Case Western Reserve University License No.: 01100180011 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 9/27-28/07 Inspector: SD 
Ohio Final Report Page C.2 

Inspection Casework Reviews

File No.: 9 

Licensee: University of Cincinnati License No.: 02110310010 

Inspection Type: Routine, Announced Priority: 1 

Inspection Dates: 8/1-3/06 Inspectors: DC, LS, MB 

File No.: 10 

Licensee: Grandview Hospital and Medical Center License No.: 02200290002 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 2/20/08 Inspector: SK 

File No.: 11 

Licensee: First Dayton Cancer Care, LLC License No.: 02230580000 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/31/07 Inspectors: LS, SK 

File No.: 12 

Licensee: Isomedix Operations License No.: 03521250028 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/10/07 Inspector: KB 

File No.: 13 

Licensee: Heartlight Pharmacy Services License No.: 02500020000 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 12/31/07 Inspector: AC 

File No.: 14 

Licensee: National Veterinary Imaging, Inc. License No.: 02400440000 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 8/11/05 Inspector: KB 

File No.: 15 

Licensee: Wright State University License No.: 01110580000 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/17/06 Inspector: SD 

File No.: 16 

Licensee: Gamma Med License No.: 02500510004 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/29/07 Inspector: MB 

File No.: 17 

Licensee: Girindus America, Inc. License No.: 03611310034 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 6/16/05 Inspector: KV 
Ohio Final Report Page C.3 

Inspection Casework Reviews

File No.: 18 

Licensee: Gamma Irradiator Service License No.: 00004NR0749 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 7/18/07 Inspector: SD 

File No.: 19 

Licensee: Weatherford International Inc. License No.: 00004NR0801 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 10/8/08 Inspector: KB 

File No.: 20 

Licensee: Cleveland State University License No.: 202-099-26 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Dates: 9/7/06 Inspector: SD 

File No.: 21 

Licensee: Fairfield Medical Center License No.: 02120230001 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Dates: 9/29-30/08 Inspector: MB 

File No.: 22 

Licensee: Lake/University Ireland Cancer Center License No.: 02230440000 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 8/2/07 Inspector: AC 

File No.: 23 

Licensee: The Cleveland Clinic Foundation License No.: 02110180013 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 3/1/07 Inspectors: AC, KV 

File No.: 24 

Licensee: Fluke Biomedical LLC License No.: 03211180000 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 10/20/06 Inspector: KV 

 INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Fairfield Medical Center License No.: 02120230001 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 10/2/08 Inspector: MB 
Ohio Final Report Page C.4 

Inspection Casework Reviews

Accompaniment No.: 2 

Licensee: American Red Cross Blood Services License No.: 03510250004 

Inspection Type: Special, Unannounced Priority: 5 

Inspection Date: 9/29/08 Inspector: CL 

Accompaniment No.: 3 

Licensee: Isomedix Operations, Inc. License No.: 03521250028 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/30/08 Inspector: KB 

Accompaniment No.: 4 

Licensee: Cardinal Health License No.: 02500310000 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/1/08 Inspector: DC 

Accompaniment No.: 5 

Licensee: Kettering Medical Center License No.: 02120580021 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/1/08 Inspector: LS 

Accompaniment No.: 6 

Licensee: Babcock & Wilcox License No.: 03310780006 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/2/08 Inspector: SD 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Summa Health System License No.: 02120780022 

Type of Action: Renewal Amendment No.: 29 

Date Issued: 7/18/08 License Reviewer: MB 

File No.: 2 

Licensee: Lima Memorial Hospital License No.: 02120002003 

Type of Action: Amendment Amendment No.: 26 

Date Issued: 7/15/08 License Reviewer: ET 

File No.: 3 

Licensee: Mount Carmel Health System License No.: 02120250034 

Type of Action: Amendment Amendment No.: 26 

Date Issued: 7/17/08 License Reviewer: SK 

File No.: 4 

Licensee: Jonathan Shiroma, DVM License No.: 02400250049 

Type of Action: Amendment Amendment No.: 7 

Date Issued: 6/24/08 License Reviewer: KB 

File No.: 5 

Licensee: Jonathan Shiroma, DVM License No.: 02400250049 

Type of Action: Amendment Amendment No.: 8 

Date Issued: 6/24/08 License Reviewer: KB 

File No.: 6 

Licensee: Reuter Stokes, INC License No.: 11300780011 

Type of Action: Renewal Amendment No.: 6 

Date Issued: 10/10/08 License Reviewer: CL 

File No.: 7 

Licensee: Ohio Medical Physics Consulting, LLC License No.: 02240250000 

Type of Action: New Amendment No.: 0 

Date Issued: 1/28/08 License Reviewer: AC 

File No.: 8 

Licensee: Philips Medical License No.: 03214180003 

Type of Action: Amendment Amendment No.: 29 

Date Issued: 10/27/07 License Reviewer: SD 
Ohio Final Report Page D.2 

License Casework Reviews

File No.: 9 

Licensee: Cardiovascular Care Unlimited License No.: 02201250075 

Type of Action: Amendment Amendment No.: 7 

Date Issued: 12/4/07 License Reviewer: SD 

File No.: 10 

Licensee: Ford Motor Company License No.: 31200990001 

Type of Action: Amendment Amendment No.: 7 

Date Issued: 12/7/07 License Reviewer: CS 

File No.: 11 

Licensee: Cincinnati Eye Institute License No.: 02140310000 

Type of Action: New Amendment No.: 0 

Date Issued: 9/17/08 License Reviewer: SK 

File No.: 12 

Licensee: GE Reuter Stokes License No.: 03214780011 

Type of Action: Amendment Amendment No.: 10 

Date Issued: 2/19/08 License Reviewer: KB 

File No.: 13 

Licensee: The Cleveland Clinic Foundation License No.: 02110180013 

Type of Action: Amendment Amendment No.: 22 

Date Issued: 3/27/07 License Reviewer: AC 

File No.: 14 

Licensee: Radiation Oncology Services LLC License No.: 02230580001 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 2/19/08 License Reviewer: DC 

File No.: 15 

Licensee: Scott Process Systems, Inc. License No.: 03320770000 

Type of Action: Renewal Amendment No.: 3 

Date Issued: 7/16/07 License Reviewer: CL 

File No.: 16 

Licensee: IRM Group, Inc. License No.: 03214250000 

Type of Action: Amendment Amendment No.: 6 

Date Issued: 9/13/06 License Reviewer: SJ 

File No.: 17 

Licensee: CBC Engineers & Associates, LTD License No.: 31210580000 

Type of Action: Amendment Amendment No.: 6 

Date Issued: 9/20/07 License Reviewer: CS 
Ohio Final Report Page D.3 

License Casework Reviews

File No.: 18 

Licensee: Miami University License No.: 01110090002 

Type of Action: Renewal Amendment No.: 7 

Date Issued: 10/5/05 License Reviewer: SD 

File No.: 19 

Licensee: American Red Cross License No.: 03510250004 

Type of Action: Amendment/Renewal Amendment No.: 2 

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

File No.: 20 

Licensee: RMI Environmental Services License No.: 11900040004 

Type of Action: Termination Amendment No.: 25 

Date Issued: 2/27/07 License Reviewers: SD, CM 

File No.: 21 

Licensee: The Cleveland Clinic Foundation License No.: 02110180013 

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

Date Issued: 10/26/07 License Reviewers: RO and staff 

File No.: 22 

Licensee: Advanced Medical Systems License No.: 03900180000 

Type of Action: Termination in progress Amendment No.: N/A 

Date Issued: Pending License Reviewers: CM and staff 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Riverside Methodist Hospital License No.: 02210250070 

Date of Incident: 11/16/04 NMED Log No.: 050066 

Investigation Dates: 1/25-28/05 Type of Incident: Overexposure to embryo/fetus 

 Type of Investigation: Site visit 

File No.: 2 

Licensee: Marietta Memorial Hospital License No.: 02120850007 

Date of Incident: 3/11/05 NMED Log No.: 050176 

Investigation Date: 3/21/05 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 3 

Licensee: Geotechnical Consultants License No.: 31210250023 

Date of Incident: 6/1/05 NMED Log No.: 050379 

Investigation Date: 6/3/05 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site Visit 

File No.: 4 

Licensee: Patriot Engineering License No.: 31210580004 

Date of Incident: 8/1/05 NMED Log No.: 050773 

Investigation Date: 8/5/05 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site Visit 

File No.: 5 

Licensee: Hockaden and Associates License No.: 31210250010 

Date of Incident: 7/11/06 NMED Log No.: 06504 

Investigation Date: 7/14/06 Type of Incident: Damage to Equipment 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: H.C. Nutting Company License No.: 31210310024 

Date of Incident: 7/30/06 NMED Log No.: 060490 

Investigation Date: 7/31/06 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Telephone 

File No.: 7 

Licensee: Ohmart/Vega License No.: 03214310020 

Date of Incident: 10/20/06 NMED Log No.: 060654 

Investigation Date: 10/25/06 Type of Incident: Release of Radioactive Material 

 Type of Investigation: Site Visit 
Ohio Final Report Page E.2 

Incident Casework Reviews

File No.: 8 

Licensee: Akron General Medical Center License No.: 02120780000 

Date of Incident: 9/27/06 NMED Log No.: 070121 

Investigation Date: 3/5/07 Type of Incident: Medical Event 

 Type of Investigation: Site Visit 

File No.: 9 

Licensee: Clinton Memorial Hospital License No.: 02300140000 

Date of Incident: 12/1/06 NMED Log No.: 070026 

Investigation Date: 1/2/07 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 10 

Licensee: Ohmart/Vega Corporation License No.: 03214310002 

Date of Incident: 2/22/08 NMED Log No.: 080123 

Investigation Date: 2/25/08 Type of Incident: Release of Radioactive Material 

 Type of Investigation: Site Visit 

File No.: 11 

Licensee: Wright State University License No.: 01110580000 

Date of Incident: 8/1/08 NMED Log No.: 080634 

Investigation Date: 8/20/08 Type of Incident: Leaking Source 

 Type of Investigation: Telephone 

File No.: 12 

Licensee: Cleveland Clinic Foundation License No.: 02110180013 

Date of Incident: 8/7/08 NMED Log No.: 080460 

Investigation Date: 8/11/08 Type of Incident: Equipment Failure 

 Type of Investigation: Site Visit 

File No.: 13 

Licensee: Team Industrial Services, Inc. License No.: 03320990000 

Date of Incident: 7/18/07 NMED Log No.: 070460 

Investigation Dates: 7/19/07 Type of Incident: Defective Equipment 

 Type of Investigation: Site Visit 

File No.: 14 

Licensee: Ohmart/Vega License No.: 03214310020 

Date of Incident: 8/14/07 NMED Log No.: 080670 

Investigation Date: 8/14/07 Type of Incident: Leaking Source 

 Type of Investigation: Telephone 

Comment: 

State did not report this event to NRC or enter it into NMED until October 2008. 
Ohio Final Report Page E.3 

Incident Casework Reviews

File No.: 15 

Licensee: Glatfelter Paper License No.: 31201720002 

Date of Incident: 4/12/06 NMED Log No.: 080671 

Investigation Date: 4/12/06 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

Comment: 

State did not report this event to NRC or enter it into NMED until October 2008. 

File No.: 16 

Licensee: ABB Inc. License No.: 03214250003 

Date of Incident: 2/23/07 NMED Log No.: 080669 

Investigation Date: 10/28/08 Type of Incident: Leaking Source 

 Type of Investigation: Telephone 

Comment: 

 State did not report this event to NRC or enter it into NMED until October 2008. 
APPENDIX F 

SEALED SOURCE & DEVICE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Registry No.: OH-0522-D-102-B SS&D Type: (D) Gamma Gauge 

Applicant Name: Ohmart/VEGA Type of Action: Amendment 

Date Issued: 11/10/05 Reviewers: KV, KB 

File No.: 2 

Registry No.: OH-0522-D-120-B SS&D Type: (D) Gamma Gauge 

Applicant Name: Ohmart/VEGA Type of Action: New 

Date Issued: 6/22/07 Reviewers: KV, KB 

File No.: 3 

Registry No.: OH-0522-D-112-S SS&D Type: (D) Gamma Gauge 

Applicant Name: Ohmart/VEGA Type of Action: Amendment 

Date Issued: 7/17/06 Reviewers: KV, SD 

File No.: 4 

Registry No.: OH-0298-S-102-S SS&D Types: (H) General Neutron Source 

 Applications, (F) Well Logging 

Applicant Name: Frontier Technology Corporation Type of Action: Amendment 

Date Issued: 5/25/05 Reviewers: KV, SD 

File No.: 5 

Registry No.: OH-1272-D-101-B SS&D Type: (D) Gamma Gauge 

Applicant Name: Kanawha Scales & Systems Type of Action: New 

Date Issued: 2/26/07 Reviewers: KB, KV 

Comment: 

The header of each attachment incorrectly identifies each attachment as “Draft” instead 

of the issue date. 

File No.: 6 

Registry No.: OH-1064-D-101-G SS&D Type: (D) Gamma Gauge 

Applicant Name: Advance Gauging Technology Type of Action: Amendment 

Date Issued: 4/4/05 Reviewers: KV, KB 

File No.: 7 

Registry No.: OH-1219-D-103-S SS&D Type: (J) Gamma Irradiation, Category I 

Applicant Name: Thermo Eberline, LLC Type of Action: Amendment 

Date Issued: 12/16/04 SS&D Reviewers: KV, KB 
Ohio Final Report Page F.2 

SS&D Casework Reviews

File No.: 8 

Registry No.: OH-0104-D-801-S SS&D Types: (B) Medical Radiography 

 (X) Medical Reference Sources 

Applicant Name: Philips Medical Systems Type of Action: Inactivation 

Date Issued: 12/14/04 SS&D Reviewers: KV, KB 

File No.: 9 

Registry No.: OH-0104-D-105-S SS&D Type: (X) Medical Reference Sources 

Applicant Name: Philips Medical Systems Type of Action: New 

Date Issued: 12/29/04 SS&D Reviewers: KB, SD 

File No.: 10 

Registry No.: OH-0522-S-119-S SS&D Type: (D) Gamma Gauge 

Applicant Name: Ohmart/VEGA Type of Action: New 

Date Issued: 11/1/05 SS&D Reviewers: KV, KB 

File No.: 11 

Registry No.: OH-1219-D-101-G SS&D Type: (W) Self-Luminous Light Source 

Applicant Name: Thermo Eberline, LLC Type of Action: New 

Date Issued: 12/16/04 SS&D Reviewers: KV, KB 
ATTACHMENT 

December 30, 2008 Letter from Alvin D. Jackson 

Ohio’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML083650309