August 29, 2011 

Ms. Sandra Breitborde, Deputy Administrator 

Division of Public Health 

Wisconsin Department of Health Services 

P.O. Box 2659 

Madison, WI 53701-2659 

Dear Ms. Breitborde: 

A periodic meeting with your program was held on August 10, 2011. The purpose of the 

meeting was to review and discuss the status of Wisconsin’s Agreement State Program. The 

Nuclear Regulatory Commission was represented by Anne Boland, Stephen Poy and me. 

I have completed and enclosed a general meeting summary, including any specific actions that 

will be taken as a result of the meeting. 

If you feel that our conclusions do not accurately summarize the meeting discussion, or have 

any additional remarks about the meeting in general, please contact me at (630) 829-9661 or 

email to james.lynch@nrc.gov to discuss your comments. 

Sincerely, 

 /RA/ 

Jim Lynch 

Regional State Agreements Officer 

Division of Nuclear Materials Safety 

Enclosure: 

As stated 

cc w/encl: Charles Warzecha 

 Director, Bureau of Environmental 

 & Occupational Health 

 Paul Schmidt, Manager 

 Radiation Protection Section 

 

 
Ms. Sandra Breitborde, Deputy Administrator 

Division of Public Health 

Wisconsin Department of Health Services 

P.O. Box 2659 

Madison, WI 53701-2659 

Dear Ms. Breitborde: 

A periodic meeting with your program was held on August 10, 2011. The purpose of the 

meeting was to review and discuss the status of Wisconsin’s Agreement State Program. The 

Nuclear Regulatory Commission was represented by Anne Boland, Stephen Poy and me. 

I have completed and enclosed a general meeting summary, including any specific actions that 

will be taken as a result of the meeting. 

If you feel that our conclusions do not accurately summarize the meeting discussion, or have 

any additional remarks about the meeting in general, please contact me at (630) 829-9661 or 

email to james.lynch@nrc.gov to discuss your comments. 

Sincerely, 

 /RA/ 

Jim Lynch 

Regional State Agreements Officer 

Division of Nuclear Materials Safety 

Enclosure: 

As stated 

cc w/encl: Charles Warzecha 

 Director, Bureau of Environmental 

 & Occupational Health 

 Paul Schmidt, Manager 

 Radiation Protection Section 

Distribution w/encl:

Anne Boland 

Pat Louden 

Allan Barker 

Lisa Dimmick 

Michelle Beardsley 

Stephen Poy 

DOCUMENT NAME: http://portal.nrc.gov/edo/riii/DNMS/Admin Documents/2011 Wisconsin Periodic Meeting Summary.docx 

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Enclosure 

AGREEMENT STATE PERIODIC MEETING SUMMARY FOR THE WISCONSIN 

DEPARTMENT OF HEALTH SERVICES 

DATE OF MEETING: AUGUST 10, 2011 

DISCUSSION: 

Agreement and Reviews

Wisconsin became the 33rd Agreement State on August 11, 2003. The Agreement discontinued 

NRC regulatory authority in the State for: a) Byproduct materials as defined in Section 11e.(1) 

of the Atomic Energy Act; b) Source materials; and c) Special nuclear materials in quantities not 

sufficient to form a critical mass. The Agreement does not cover land disposal of radioactive 

material, uranium recovery processes, or sealed source and device evaluation. 

The last Integrated Materials Performance Evaluation Program (IMPEP) review of the 

radioactive materials program was conducted in 2009. All performance indicators were found to 

be satisfactory and no recommendations were made. The Wisconsin program was found to be 

adequate to protect public health and safety and compatible with NRC=s program. The State’s 

initial IMPEP review, in 2005, yielded similar results. 

Organization

The Radiation Control Program is administered by the Radiation Protection Section, Division of 

Public Health, Department of Health Services. Paul Schmidt is the Manager of the Radiation 

Protection Section. Cheryl Rogers is the Supervisor of the Radioactive Materials Licensing and 

Inspection Unit, which is part of the Section. Wisconsin regulates approximately 322 specific 

licenses, including naturally occurring or accelerator-produced radioactive material (NARM). 

Management support for the program appears good and the program is well funded. A 

dedicated fee fund allows the program to be 100% fee recoverable. 

Cheryl Rogers is Chair-Elect of the Organization of Agreement States (OAS). Paul Schmidt has 

previously chaired the OAS and the Conference of Radiation Control Program Directors, Inc. 

Mr. Schmidt is also the State Liaison Officer. 

 

NRC Attendees Wisconsin Attendees

Jim Lynch, RSAO Sandy Breitborde, Deputy Administrator 

Anne Boland, Director, DNMS Chuck Warzecha, Bureau Director 

Steve Poy, FSME Paul Schmidt, Section Manager 

Cheryl Rogers, Unit Supervisor 
Wisconsin Periodic Meeting Summary Page 2 

Enclosure 

Agreement State Program Staffing

Despite a general Department hiring freeze, program managers have been able to hire staff, 

through an exemption process, to address significant turnover in the program. Several senior 

staff members left the program for retirement or other job opportunities. The program is 

adequately staffed, with a total of 7.5 FTE dedicated to the inspection and licensing programs. 

One vacancy exists, but has not been posted. A recent retiree was hired back on a temporary 

basis to provide continuity in the program. 

One of the staff members is located in the Green Bay field office. All staff members are crosstrained in both inspection and licensing to provide maximum flexibility and backup. 

Training

A training matrix was developed for all employees to track their training history. Formalized 

training requirements were developed for inspectors and license reviewers. Ms. Rogers and 

senior health physics staff train and accompany each inspector before certifying them to 

conduct independent inspections. 

With several new staff members in the program needing licensing training, in 2010, Mr. Schmidt 

requested that Region III provide training for license reviewers. Colleen Casey, of the Region III 

office, provided a week-long licensing training session in Madison. Mr. Schmidt stated that the 

training was extremely valuable and he appreciated the positive working relationship that 

Wisconsin has with Region III. 

The Department has imposed an out-of-State travel restriction for all employees. Exemptions to 

the restriction have been received when the training need is essential to the program. 

Materials Inspection Program 

Wisconsin inspection frequencies are at least as frequent as found in NRC’s Inspection Manual 

Chapter (IMC) 2800. Ms. Rogers said that a few inspections are currently overdue. She was 

well aware of the due dates but made informed decisions based on program priorities. New 

licensees are inspected within 12 months of license issuance, regardless of whether the 

licensee has received radioactive material. Reciprocity inspections are performed in 

accordance with the frequencies identified in NRC Manual Chapter 1220. 

Ms. Rogers stated that they plan to have inspectors provide handouts to licensees emphasizing 

the need for a positive safety culture in licensee programs. 

Materials Licensing Program

Ms. Rogers stated that no significant licensing backlogs exist; however, with the ongoing 

training of newer staff, some actions have exceeded their timeliness goals. She stated that prelicensing visits are performed for all new license applicants. A pre-licensing checklist is used for 

all licensing actions. 

As a direct result of the afore-mentioned licensing training by Region III, Ms. Rogers indicated 

that the licensing backlog was significantly decreased. 

 
Wisconsin Periodic Meeting Summary Page 3 

Enclosure 

Mr. Schmidt discussed the need for a close working relationship between NRC and Wisconsin 

on a potential license for SHINE Medical Technologies which is proposing an accelerator-based 

system to produce medical isotopes, including molybdenum-99. 

Regulations

To date, the State=s regulations are mostly up-to-date and compatible. A regulation review letter 

was sent to the State in July 2010 identifying seven corrections to the regulations which need to 

be implemented. Ms. Rogers stated that those items would be addressed in the next 

rulemaking. The rulemaking process in Wisconsin typically takes 1.5 years to complete. 

State managers are aware of the significant changes to medical and security regulations which 

will need to be promulgated in the near future. 

Security

According to Wisconsin managers, Increased Controls inspections are being performed on 

schedule, in conjunction with routine inspections. 

The State has accurately updated the National Source Tracking System interim inventory with 

information for Wisconsin licensees. 

Incidents

Wisconsin staff members responded to approximately 19 reportable incidents since the last 

IMPEP review. On-site inspections were performed, when appropriate, and staff communicated 

reportable incidents promptly to the NRC Operations Center and to Region III. 

Wisconsin has done extensive evaluations of all of the prostate seed therapy programs licensed 

in the State. They have been active in the National development of radiation therapy 

regulations and guidelines. 

Two Abnormal Occurrences were identified at Wisconsin medical licensee facilities in the 

current fiscal year. Summaries of those events will be submitted to the Regional State 

Agreements Officer for inclusion in the annual report to Congress. 

Wisconsin’s investigation of an incident at a medical facility involving a high-dose rate remote 

afterloader identified a potential generic problem with an applicator. The incident data was 

provided to Steve Poy to pass to the NRC medical group in FSME for evaluation. 

Inspectors input incident information directly into the Nuclear Material Events Database (NMED) 

as incidents occur. A review of NMED identified timely and quality input of incidents. 

Allegations

One allegation, involving a State industrial facility, was transferred to Wisconsin from NRC since 

the last IMPEP review. The allegation involved potential excessive radiation levels and 

improperly stored radioactive waste. Wisconsin staff investigated the allegation and took 

prompt, appropriate action, including feedback to the alleger. Investigation results were 

provided to the Regional State Agreements Officer. 
Wisconsin Periodic Meeting Summary Page 4 

Enclosure 

General Licenses

Wisconsin has an active program for registering generally licensed devices. General licensees 

are required to update inventories on an annual basis. Inspections of these licensees are 

performed as time permits. 

Current NRC Initiatives: 

NRC staff discussed ongoing initiatives with the Wisconsin representatives. These included: 

medical rulemaking and workshops; brachytherapy guidance; control of sensitive information; 

NRC’s enforcement guidance for portable gauges; and the recently published Inspection 

Manual Chapter 1248 which regards staff training and qualification. 

CONCLUSIONS:

The Wisconsin Radiation Control Program remains a very active, strong Agreement State 

program. Although staffing has been challenging over the past several years, program 

managers have been able to hire and train qualified personnel. 

Management support for the program is very good. The managers liked the IMPEP process 

and saw great benefit in Wisconsin=s participation in the program. The NRC representatives 

urged the managers to consider allowing senior staff members to participate on future IMPEP 

teams. 

Schedule for the Next IMPEP Review: 

NRC staff recommends that the next IMPEP review, currently scheduled for 2013, be extended 

to 2014, in accordance with the IMPEP Self-Assessment Working Group report from August 

2010. Recommendation 3 of the Working Group’s report recommends that consistently high 

performing organizations that have two consecutive IMPEP reviews with findings of satisfactory 

on all performance indicators be recognized for its achievements.