January 31, 2011 

Maureen E. Dempsey, M.D., FAACP 

Chief Deputy for Public Health 

Virginia Department of Health 

P.O. Box 2448 

Richmond, VA 23218 

Dear Dr. Dempsey: 

On January 12, 2011, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Virginia Agreement State Program adequate to 

protect public health and safety and compatible with the U.S. Nuclear Regulatory Commission’s 

(NRC) 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 

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

meeting tentatively scheduled for November 2012. 

During the periodic meeting and at the next IMPEP review, NRC will evaluate the effectiveness 

of the Commonwealth’s response to the review team’s recommendation and the overall 

implementation of your Agreement State Program. 

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/ 

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Virginia Final IMPEP Report 

cc: Leslie Foldesi, Director 

 Division of Radiological Health 

 
Maureen E. Dempsey, M.D., FAACP 

Chief Deputy for Public Health 

Virginia Department of Health 

P.O. Box 2448 

Richmond, VA 23218 

Dear Dr. Dempsey: 

On January 12, 2011, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Virginia Agreement State Program adequate to 

protect public health and safety and compatible with the U.S. Nuclear Regulatory Commission’s 

(NRC) 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 

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

meeting tentatively scheduled for November 2012. 

During the periodic meeting and at the next IMPEP review, NRC will evaluate the effectiveness 

of the Commonwealth’s response to the review team’s recommendation and the overall 

implementation of your Agreement State program. 

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/

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Virginia Final IMPEP Report 

cc: Leslie Foldesi, Director 

 Division of Radiological Health 

DISTRIBUTION: 

See next page

ADAMS ACCESSION NO.: ML110140022 (pkg.) 

OFC FSME/MSSA FSME/MSSA FSME/MSSA FSME/MSSA TechEd FSME DEDMRT 

NAME MBeardsley DWhite TReis RLewis CPoland CMiller MFWeber 

DATE 01/14/11 01/18/11 01/18/11 01/21/11 01/25/11 01/27/11 01/31/11 

OFFICIAL RECORD COPY 
Letter to Maureen E. Dempsey from Michael F. Weber dated January 31, 2011 

SUBJECT: VIRGINIA 2010 FINAL IMPEP REPORT 

DISTRIBUTION: EDATS: FSME-2011-0012 

MSSA_Technical_Asst_Resource DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsOgcMailCenter 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

MBeardsley, FSME/MSSA Commissioner Svinicki 

DJanda, RI/RSAO Commissioner Apostolakis 

LDimmick, FSME/MSSA Commissioner Magwood 

MOrendi, RI/RSAO Commissioner Ostendorff 

JKinneman, NMSS SECY 

RLorson, RI 

MWelling, VA 

MWeber, OEDO 

KBrock, OEDO 

BJones, OGC 

JBiggins, OGC 

Cynthia Sanders, Georgia 

JLynch, RIII 

KLambert, RIII 

JOlmstead, OGC 

JWeil, OCA (2 copies) 

Mark Light, Ohio 
 Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE VIRGINIA AGREEMENT STATE PROGRAM 

NOVEMBER 1-5, 2010 

FINAL REPORT
Virginia Final Report

EXECUTIVE SUMMARY 

This report presents the results of the initial IMPEP review of the Virginia Agreement State 

Program. The review was conducted during the period of November 1-5, 2010, by a review 

team composed of technical staff members from the U.S. Nuclear Regulatory Commission 

(NRC) and the State of Ohio.

Based on the results of this review, Virginia’s performance was found satisfactory for all six 

performance indicators reviewed. The review team made one recommendation regarding the 

performance of the Virginia Agreement State Program. The review team recommends that the 

Commonwealth implement, use, and update the licensing and inspection qualification journals 

for each staff member. 

Accordingly, the review team recommended, and the MRB agreed, that the Virginia Agreement 

State Program be found adequate to protect public health and safety and compatible with 

NRC's program. 

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

place in approximately 4 years.
Virginia Final Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of November 1-5, 2010, by a review team composed of 

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

Ohio. This was the initial review of the program since the Agreement was signed in 

March 2009. 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 March 31, 2009, to November 5, 2010, were discussed with 

Virginia managers on the last day of the review. 

A draft of this report was issued to Virginia for factual comment on November 22, 2010. The 

State responded by letter dated December 21, 2010, from Maureen Dempsey, M.D., Chief 

Deputy for Public Health. A copy of the Commonwealth’s response is included as the 

Attachment to this report. The Management Review Board (MRB) met on January 12, 2011, to 

consider the proposed final report. The MRB found the Virginia Agreement State Program 

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

The Virginia Agreement State Program is administered by the Radioactive Materials Program 

(the Program), in the Division of Radiological Health (the Division). The Division is part of the 

Virginia Department of Health, Office of Epidemiology. Organization charts for the 

Commonwealth, the Division, and the Program are included as Appendix B. 

At the time of the review, the Virginia Agreement State Program regulated 424 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 the NRC and the Commonwealth of Virginia. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on July 21, 2010. The Program 

provided its response to the questionnaire on October 19, 2010. A publicly available version of 

the questionnaire response can be found in NRC’s Agencywide Documents Access and 

Management System (ADAMS) using the Accession Number ML102920712. 

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 Virginia statutes and 

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

review of selected regulatory actions; (5) field accompaniments of three inspectors; and 

(6) interviews with staff and managers. The review team evaluated the information gathered 

against the established criteria for each common and the applicable non-common performance 

indicator and made a preliminary assessment of the Virginia Agreement State Program’s 

performance. 

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 
Virginia Final Report Page 2 

indicators, and Section 4.0 summarizes the review team's findings and recommendations. The 

review team’s recommendations are comments that relate directly to program performance by 

the Commonwealth. A response is requested from the Commonwealth to all recommendations 

in the final report. 

2.0 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. 

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 managers and staff, reviewed job descriptions and training records, and 

considered any workload backlogs. 

The Virginia Agreement State Program is composed of the Program Manager, four Radiation 

Safety Specialists, and one Program Assistant. Two Radiation Safety Specialists are located in 

the main office in Richmond, and the other two are located out of their homes in Bristol and 

Yorktown. Having two of the Radiation Safety Specialists work remotely allows program 

coverage of the entire Commonwealth on short notice, if required. Each Radiation Safety 

Specialist has at least a bachelor’s degree in a physical or life science and has several years of 

professional experience in radiation protection. Technical staff conducts inspections, performs 

licensing actions, and responds to incidents and allegations based on individual qualifications. 

Technical staff also performs emergency response duties as necessary. Based on information 

provided by the Program, the review team estimated that the Program expends approximately 

4.25 full-time equivalents (FTE) to administer the Agreement State program. 

During the review period, one Radiation Safety Specialist and one Program Assistant left the 

Agreement State program and one Radiation Safety Specialist joined the Program. At the time 

of the review, the Program had one vacancy in the Agreement State program: the Program 

Assistant position. The position became vacant in August 2010 after the former Program 

Assistant left the Program. The review team noted that the Program Assistant’s duties have 

been temporarily absorbed by the Program Manager and various technical staff members. At 

the time of the review, the Program had received permission to fill the vacancy and had plans to 

post the position the following week. The review team concluded that the vacancy does not 

have a major impact on the day-to-day operations of the Agreement State program, as licensing 

and inspection backlogs have not developed since the position became vacant. 

The Program has a documented training plan for technical staff that is consistent with the 

requirements in the NRC/Organization of Agreement States Training Working Group Report and 

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

Material Safety and Safeguards Program Area.” The Program uses on-the-job training, such as 

inspector accompaniments, to supplement formal coursework. Staff members are typically 
Virginia Final Report Page 3 

assigned increasingly complex duties as they progress through the qualification process. Staff 

members are authorized to perform regulatory duties independently after demonstrating 

competency. In the Commonwealth’s application to become an Agreement State, the 

Commonwealth submitted and committed to using qualification journals for each of its staff 

members. The review team found that while qualification journals were started when the 

Commonwealth became an Agreement State, their continued use for current staff and 

implementation for new staff has not been sustained. The review team recommends that the 

Commonwealth implement, use, and update the licensing and inspection qualification journals 

for each staff member. At the time of the MRB meeting, the Commonwealth reported that they 

have updated and are now implementing licensing and inspection qualification journals for every 

staff member. 

The review team noted that the Program managers encourage and support training 

opportunities, based on program needs. The review team concluded that the Program’s staffing 

and training is adequate to carry out its regulatory duties. 

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

that Virginia’s performance with respect to the indicator, Technical Staffing and Training, be 

found 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 issuance 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 members. 

The review team verified that Virginia's inspection frequencies for all types of radioactive 

material licenses are at least the same frequency as NRC’s inspection frequencies, listed in IMC 

2800, “Materials Inspection Program.” The Virginia program inspects small medical facilities, 

where written directives are not required, at three year intervals, rather than the five-year 

interval in IMC 2800. 

The Program conducted a total of 63 inspections of high priority (Priority 1, 2, and 3) licensees 

and 7 initial inspections during the review period. Of the 63 high priority inspections, the review 

team determined that two inspections were completed overdue by more than 25 percent of the 

inspection frequency prescribed in IMC 2800. The review team also verified that no high priority 

inspections were overdue at the time of the review. As required by IMC 2800, initial inspections 

should be conducted within 12 months of license issuance. The review team verified that there 

were no overdue initial inspections at the time of the review and that the 7 initial inspections 

were conducted within 12 months of license issuance. Overall, the review team calculated that 

the Program performed 2.8 percent of its inspections overdue during the review period. 

The review team evaluated the Program’s timeliness of issuance of inspection findings. The 

Program has a goal of issuing inspection correspondence within 30 days of the final date of the 

inspection. The program issued the results of 96 inspections during the review period and 
Virginia Final Report Page 4 

28 were issued greater than 30 days after the final inspection date. The review team 

determined that the majority of inspection findings were issued within the 30-day goal. 

During the review period, the Program received requests for reciprocity from 64 candidate 

licensees, and performed inspections of 28 percent of those licensees. The Program exceeded 

the criterion in IMC 1220 “Processing of NRC Form 241 and Inspection of Agreement State 

Licensees Operating Under 10 CFR 150.20,” that requires on-site inspection of 20 percent of 

candidate licensees operating under reciprocity. 

The Program had 34 licensees that were subject to the Increased Controls at the time of the 

review. Initial Increased Control inspections were completed by the NRC prior to this review 

period. The review team noted that follow-up Increased Controls and National Source Tracking 

System inspections were being conducted during the routine inspections of these licensees. 

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

that Virginia's performance with respect to the indicator, Status of Materials Inspection Program, 

be found satisfactory. 

2.3 Technical Quality of Inspections

The review team evaluated 27 inspection reports that included enforcement documentation and 

letters to licensees, and interviewed a number of inspectors who were responsible for 

radioactive materials inspections conducted during the review period. The casework examined 

included a cross-section of inspections conducted by six current and former inspectors and 

covered a wide variety of inspection types involving initial, routine, and special inspections. The 

casework included inspection of various types of programs including: academic, medical private 

practice, medical institution, mobile nuclear medicine service, high dose-rate remote 

afterloaders, nuclear pharmacies, industrial radiography, and manufacturing and distribution. 

Appendix C lists the inspection casework files reviewed. 

Based on the evaluation of casework, the review team determined that inspection reports were 

thorough, complete, consistent, and of high quality with sufficient documentation to ensure that 

licensees’ performances with respect to health, safety, and security were acceptable. 

Inspection report documentation supported violations, recommendations made to licensees, 

unresolved safety issues, and discussions held with licensees during exit interviews. The 

review team also evaluated the Program’s handling and storing of sensitive documents. The 

review team determined that documents containing sensitive and security-related information 

were appropriately protected, and maintained in a manner to limit access. The review team 

found that outgoing correspondence was marked, as appropriate. 

The Program has a policy to accompany all staff performing radioactive materials inspections on 

an annual basis. The review team verified that all qualified inspectors were accompanied in 

2009 by the Program Manager. The review team verified that two of the three qualified 

inspectors were accompanied in 2010. The Program Manager indicated that the remaining 

qualified inspector will be accompanied before the end of 2010. At the time of the MRB 

meeting, the Commonwealth reported that the remaining inspector was accompanied in 

December 2010. 
Virginia Final Report Page 5 

The review team noted that the Program maintains an adequate supply of appropriately 

calibrated survey instruments to support the inspection program, as well as to respond to 

radioactive materials incidents and emergency conditions. The Program has contracts with two 

separate entities to perform instrument calibration and repair. All survey instruments observed 

at the time of the review were within their calibration dates. The Division maintains a mobile 

laboratory with the capability of analyzing wipes and other samples as necessary. This mobile 

lab is the primary resource for the Division. The Division uses another Commonwealth agency 

to analyze wipes and other samples whenever the workload exceeds its laboratory’s capacity. 

The review team accompanied three of the Program’s inspectors in October 2010. The 

inspectors conducted inspections at a medical brachytherapy licensee, an industrial radiography 

licensee, and a gamma stereotactic radiosurgery licensee. The inspector accompaniments are 

listed in Appendix C. The inspectors demonstrated performance-based inspection techniques 

and knowledge of the regulations. The inspectors were well trained, prepared for the 

inspections, 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 inspectors held entrance and exit meetings with the appropriate level of licensee 

management. 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 recommends, and the MRB agreed, 

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

found satisfactory. 

2.4 Technical Quality of Licensing Actions

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

27 specific licensing actions. Licensing actions were reviewed for completeness, consistency, 

proper radioisotopes and quantities, 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 technical quality. 

The casework was also reviewed for timeliness, use of appropriate deficiency letters and cover 

letters, reference to appropriate regulations, supporting documentation, consideration of 

enforcement history, pre-licensing visits, peer/supervisory review, and proper signatures. The 

licenses are also clearly marked to document Official Use Only-Security Related Information as 

appropriate. 

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

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

3 new licenses, 5 renewals, 4 decommissioning or termination actions, and 15 amendments. 

Files reviewed included a cross-section of license types, including: medical diagnostic and 

therapy, brachytherapy, industrial radiography, research and development, nuclear pharmacy, 

gauges, and manufacturers. The casework sample represented work from each of the license 

reviewers. A listing of the licensing casework reviewed is provided in Appendix D. 

On March 31, 2009, NRC transferred approximately 400 specific licenses to Virginia’s 

jurisdiction. The Program merged the NRC licenses with existing Program licenses for naturally 

occurring and accelerator-produced radioactive materials. As a result, the Program had 
Virginia Final Report Page 6 

approximately 424 licenses at the time of the review. The majority of the license amendments 

completed by the Program during the review period consisted of merging NRC licenses into 

Virginia licenses and reformatting all of the NRC licenses into the Program’s license template. 

The Program completed 39 license renewals, 20 new licenses, and 16 decommissioning 

licensing actions during the review period. All licensing actions are initially entered into the 

Program’s computer tracking system called RAM 2000 (a Microsoft Access based program). 

The licensing actions are uploaded to the RAM 2000 system so that information is readily 

available to the license reviewers. License reviewers use checklists and boilerplate licenses 

specific to the type of licensing actions to ensure consistency in licenses. The Program enters 

information into RAM 2000 which documents license number, staff assignment, type of license 

action, the date received, and final quality assurance review date. The final quality assurance 

review is performed by the Program Manager, who signs each licensing action. 

Based on the casework evaluated, the review team concluded that the licensing actions were of 

high quality and consistent with the NUREG-1556 guidance documents, the Commonwealth’s 

regulations, and good health physics practices. The review team attributed the consistent use 

of templates and quality assurance reviews to the overall quality noted in the casework reviews. 

The Program performs pre-licensing checks of all new applicants. The Program’s methods 

incorporate the essential elements of NRC’s revised pre-licensing guidance to verify that the 

applicant will use requested radioactive materials as intended. The Program checks applicants 

without a known radioactive materials license from another agency against records with the 

State of Virginia Corporation Office for proper business registration. In addition, the Program 

uses various on-line search mechanisms and interagency communications to verify the identity 

of individuals. If a pre-licensing visit is necessary, each applicant is subject to an on-site 

evaluation of their radiation safety and security programs prior to receipt of the initial license. 

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

and Fingerprinting Orders. The review team noted that the Commonwealth has adopted 

regulations that meet the criteria for implementing the Increased Controls, including 

fingerprinting, as appropriate. The review team analyzed the Program’s methodology for 

identifying those licenses and found the rationale was thorough and accurate. The review team 

confirmed that license reviewers evaluated new license applications and license amendments 

using the same criteria. The Program requires full implementation of the Increased Controls 

prior to issuance of a new license or license amendment that meets the established criteria. 

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

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

be found 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 Virginia in the Nuclear Material Events 

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

for 11 reported radioactive materials incidents. A listing of the casework examined, with casespecific comments, can be found in Appendix E. The review team also evaluated the Program’s 
Virginia Final Report Page 7 

response to one allegation involving radioactive materials. The NRC did not refer any 

allegations to the Commonwealth during the review period. 

When notified of an incident or an allegation, the Program Manager and staff discuss the initial 

response and the need for an on-site investigation, based on the safety significance. If the 

incident meets the reportability thresholds, as established in the Office of Federal and State 

Materials and Environmental Management Programs (FSME) Procedure SA-300 “Reporting 

Material Events,” the Program notifies the NRC Headquarters Operations Center and enters the 

information into NMED, in a prompt manner. 

The incidents selected for review included a medical event, lost and stolen radioactive material, 

and damaged equipment. The review team determined that the Program’s responses to 

incidents were thorough, complete, and comprehensive in all instances. In all 11 cases, the 

Program immediately dispatched inspectors to the site when the possibility of an immediate 

threat to public health and safety existed. Although the investigations were adequate, the 

review team noted inconsistent documentation of the investigations. The Program Manager 

stated that more attention would be given to the documentation aspect. 

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

evaluated the casework for one allegation. The review team concluded that the Program took 

prompt and appropriate action in response to concerns raised. The review team noted that the 

Program thoroughly documented the investigation and retained all necessary documentation to 

appropriately close the allegation. The Program notified the alleger of the conclusion of the 

investigation. The review team determined that the Program adequately protected the identity 

of allegers. 

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

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

Allegation Activities, be found satisfactory. 

3.0 NON-COMMON PERFORMANCE INDICATORS 

Four non-common performance indicators are used to review Agreement State Programs: 

(1) Compatibility Requirements, (2) Sealed Source and Device Evaluation Program, (3) Lowlevel Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. The NRC’s 

Agreement with the Commonwealth of Virginia does not relinquish authority to regulate a sealed 

source and device evaluation program, a low-level radioactive waste disposal program, or a 

uranium recovery program, so only the first non-common performance indicator was applicable 

to this review. 

3.1 Compatibility Requirements

3.1.1 Legislation

Virginia became an Agreement State on March 31, 2009. Legislative authority to create the 

program and enter into an Agreement with NRC is granted in the Code of Virginia 32.1-228.1 

and 32.1-235. The Department of Health is designated as the state radiation control agency. 
Virginia Final Report Page 8 

In addition to its response to the questionnaire, the Commonwealth provided the review team 

with a copy of the legislation that affects the radiation control program. There have been no 

changes since the effective date of the Agreement. Virginia regulations are not subject to 

sunset laws. 

3.1.2 Program Elements Required for Compatibility 

Virginia’s regulations for control of radiation are located in the Virginia Administrative Code, 

Title 12, Agency 5, Chapter 481, and apply to all persons who receive, possess, use, transfer, 

own, or acquire any source of radiation. Virginia requires a license for the receipt, possession, 

use, transfer, ownership, or acquisition, of radioactive material. Virginia also requires the 

registration of ionizing radiation machine facilities. 

The review team evaluated the Program’s response to the questionnaire, reviewed the status of 

regulations required to be adopted by the Commonwealth 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. 

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

legally binding requirements no later than 3 years after the effective date of NRC’s regulations. 

At the time of this review, Virginia had no overdue regulations and has completed all 

outstanding regulation changes through the last NRC final rulemaking which was issued in 

2009. 

The Commonwealth adopts some NRC regulations by reference and uses legally binding 

requirements such as license conditions as appropriate. Virginia regulations that are adopted 

by reference “point” to NRC regulations, so that if the NRC modifies a regulation, the change is 

automatic for the Commonwealth’s regulations. If the NRC develops a new regulation section, 

such as the upcoming 10 CFR Part 37 security requirements rule, or updates regulations that 

the Commonwealth does not adopt by reference, the Commonwealth must create a new section 

in their regulations or update their regulations accordingly. The Commonwealth’s regulatory 

process typically takes approximately two years to complete, which includes time for public 

comment. 

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

that Virginia’s performance with respect to the indicator, Compatibility Requirements, be found 

satisfactory. 
Virginia Final Report Page 9 

4.0 SUMMARY 

As noted in Sections 2.0 and 3.0 above, the review team found Virginia’s performance to be 

satisfactory for all performance indicators reviewed. The review team made one 

recommendation regarding the performance of the Commonwealth. Overall, the review team 

recommends, and the MRB agreed, that the Virginia Agreement State Program be found 

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 recommends, and the MRB agreed, that 

the next full IMPEP review take place in approximately 4 years. 

Below is the review team’s recommendation, as mentioned in an earlier section of the report, for 

evaluation and implementation by the Commonwealth: 

The review team recommends that the Commonwealth implement, use, and update the 

licensing and inspection qualification journals for each staff member. (Section 2.1)
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Virginia Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

James Lynch, Region III Team Leader 

 Technical Quality of Incident and 

 Allegation Activities 

 Inspector Accompaniments 

Monica Orendi, FSME Technical Staffing and Training 

 Compatibility Requirements 

Kenneth Lambert, Region III Status of Materials Inspection Program 

 Technical Quality of Inspections 

Mark Light, Ohio Technical Quality of Licensing Actions 

Donna Janda, Region I Inspector Accompaniments 
APPENDIX B 

VIRGINIA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML102920715
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: G. E. Inspection Services License No.: 760-327-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 1/29/10 Inspectors: LM, MW 

Comment: 

Inspection was performed 1 month overdue. 

File No.: 2 

Licensee: M. Rafiq Zaheer, M.D. License No.: 013-132-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 10/1/10 Inspector: BS 

Comment: 

Inspection was performed 2 months overdue. 

File No.: 3 

Licensee: Best Medical International, Inc. License No.: 059-018-1 

Inspection Type: Special, Unannounced Priority: 5 

Inspection Date: 11/5/09 Inspectors: CC, MW 

File No.: 4 

Licensee: Clinch Valley Physicians License No.: 185-491-1 

Inspection Type: Initial, Announced Priority: 3 

Inspection Date: 7/14/09 Inspector: KG 

File No.: 5 

Licensee: Riverside Physicians Associates, Inc. License No.: 830-050-2 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 7/21/09 Inspector: BS 

Comment: 

Inspection letter to licensee issued in 36 days. 

File No.: 6 

Licensee: Lewis Gale Medical Center License No.: 161-126-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/13/10 Inspector: KG 

 
Virginia Final Report Page C.2 

Inspection Casework Reviews 

File No.: 7 

Licensee: Lewis Gale Physicians License No.: 161-127-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/19/09 Inspector: KG 

Comment: 

Inspection report could not be found in the license file. 

File No.: 8 

Licensee: Froehling & Robertson, Inc. License No.: 760-096-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 9/1/09 Inspectors: KG, LM 

Comment: 

Licensee’s response to notice of violation could not be found in the license file. 

File No.: 9 

Licensee: Blue Ridge Isotopes, LLC License No.: 161-449-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/14/10 Inspector: KG 

Comments: 

a) Inspection report and letter to the licensee could not be found in the license file. 

b) Inspection letter to licensee issued in 45 days. 

File No.: 10 

Licensee: Advex Corporation License No.: 650-254-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/16/09 Inspector: BS 

File No.: 11 

Licensee: Pole Brothers Imaging Company License No.: 069-451-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/25/10 Inspectors: LM, MW 

File No.: 12 

Licensee: Eastern Virginia Medical School License No.: 710-080-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/27/10 Inspector: BS 

File No.: 13 

Licensee: Virginia Polytechnic Institute and State University License No.: 121-225-1 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 11/9-12/09 Inspectors: MW, CC, KG 

 
Virginia Final Report Page C.3 

Inspection Casework Reviews 

File No.: 14 

Licensee: Martin Industrial Testing, Inc. License No.: 087-366-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 9/10/09 Inspectors: CC, LM 

File No.: 15 

Licensee: J. Core Drilling, Inc. License No.: 059-354-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/22/09 Inspectors: CC, LM 

Comment: 

Inspection letter to licensee issued in 33 days. 

File No.: 16 

Licensee: Positron Emission Tomography Institute of Hampton Road License No.: 710-163-1 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 11/10/09 Inspector: BS 

File No.: 17 

Licensee: Fairfax Radiological Consultants, P.C. License No.: 600-091-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 10/22/09 Inspectors: CC, LM 

Comment: 

Inspection letter to licensee issued in 39 days. 

File No.: 18 

Licensee: Rogan and O'Brien Cardiovascular License No.: 059-183-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/10/10 Inspector: MW 

File No.: 19 

Licensee: Cardiac and Vascular Care of Virginia, P.C. License No.: 059-030-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/19/10 Inspector: MW 

File No.: 20 

Licensee: MISTRAS Group, Inc. License No.: 760-498-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 2/17/10 Inspector: CC 

Comment: 

Inspection report could not be found in the license file. 

 
Virginia Final Report Page C.4 

Inspection Casework Reviews 

File No.: 21 

Licensee: Martha Jefferson Hospital License No.: 540-137-1 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 11/18/09 Inspectors: LM, CC 

File No.: 22 

Licensee: Lewis Gale Medical Center License No.: 161-126-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 6/16/10 Inspector: KG 

File No.: 23 

Licensee: Riverside and University of Virginia Radiosurgery Center License No.: 700-521-1 

Inspection Type: Initial, Special, Announced Priority: 2 

Inspection Date: 10/14/10 Inspector: BS 

File No.: 24 

Licensee: Waggoner and Associates License No.: Reciprocity 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 10/29/09 Inspector: KG 

File No.: 25 

Licensee: JANX Integrity Group License No.: Reciprocity 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 9/1/09 Inspector: BS 

File No.: 26 

Licensee: Thermo Process Instruments License No.: Reciprocity 

Inspection Type: Special, Unannounced Priority: 3 

Inspection Date: 4/19/10 Inspector: BS 

File No.: 27 

Licensee: Terracon Consultants, Inc. License No.: Reciprocity 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 5/3/10 Inspector: KG 

 
Virginia Final Report Page C.5 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Chippenham and Johnston-Willis Hospitals, Inc. License No.: 041-058-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 10/13/10 Inspector: KG 

Comment: 

The inspector reviewed only one patient therapy file. 

Accompaniment No.: 2 

Licensee: Martin Industrial Testing, Inc. License No.: 087-366-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 10/14/10 Inspector: CC 

Accompaniment No.: 3 

Licensee: Riverside & University of Virginia Radiosurgery Center License No.: 700-521-1 

Inspection Type: Special, Unannounced Priority: 2 

Inspection Date: 10/14/10 Inspector: BS 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: MISTRAS Group, Inc. License No.: 760-498-1 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 9/23/10 License Reviewer: CC 

File No.: 2 

Licensee: Virginia Polytechnic Institute & State University License No: 121-225-1 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 10/28/10 License Reviewer: CC 

File No.: 3 

Licensee: Best Medical International, Inc. License No.: 059-018-1 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 2/26/10 License Reviewer: CC 

File No.: 4 

Licensee: Best Medical International, Inc. License No.: 059-018-2 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 2/26/10 License Reviewer: CC 

File No.: 5 

Licensee: Spurlock Equine Associates License No.: 107-416-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 5/4/10 License Reviewer: MW 

File No.: 6 

Licensee: Carolina NDT, Inc. License No.: 191-502-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 3/30/10 License Reviewer: MW 

File No.: 7 

Licensee: Nydree Flooring, LLC License No.: 019-326-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 2/17/10 License Reviewer: MW 

File No.: 8 

Licensee: Babcock & Wilcox, Nuclear Operations Group License No.: 680-028-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 7/12/10 License Reviewer: MW 

 
Virginia Final Report Page D.2 

License Casework Reviews 

File No.: 9 

Licensee: Pole Brothers Imaging Company License No.: 069-451-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 3/9/10 License Reviewer: MW 

File No.: 10 

Licensee: Dominion NDT Services, Inc. License No.: 041-527-1 

Type of Action: New Amendment No.: 0 

Date Issued: 4/1/10 License Reviewer: CC 

File No.: 11 

Licensee: Well Data Services License No.: 027-444-1 

Types of Action: Amendment Amendment Nos.: Initial Conversion 

Date Issued: 2/17/10 License Reviewer: MW 

File No.: 12 

Licensee: Eastern Virginia Medical School License No.: 710-080-1 

Types of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 8/16/10 License Reviewer: MW 

File No.: 13 

Licensee: Riverside Shore Memorial Hospital License No.: 131-194-1 

Type of Action: Renewal Amendment No.: 1 

Date Issued: 2/10/10 License Reviewer: LM 

File No.: 14 

Licensee: All Pro Services, Inc. License No.: 600-008-1 

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

Date Issued: 5/24/10 License Reviewer: LM 

File No.: 15 

Licensee: Bassett Furniture Industries, Inc. License No.: 089-269-1 

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

Date Issued: 1/28/10 License Reviewer: LM 

File No.: 16 

Licensee: Patton, Harris, Rust & Associates License No.: 107-392-1 

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

Date Issued: 11/19/09 License Reviewer: LM 

File No.: 17 

Licensee: Hampton University Proton Therapy Institute License No.: 650-538-1 

Type of Action: New Amendment No.: 0 

Date Issued: 6/25/10 License Reviewer: CC 

 
Virginia Final Report Page D.3 

License Casework Reviews 

File No.: 18 

Licensee: Mary Immaculate Hospital, Inc. License No.: 700-138-1 

Type of Action: Renewal Amendment No.: 2 

Date Issued: 10/27/10 License Reviewer: BS 

File No.: 19 

Licensee: Augusta Health License No.: 015-015-1 

Type of Action: Renewal Amendment No.: 3 

Date Issued: 10/28/10 License Reviewer: AF 

File No.: 20 

Licensee: Inova Reston MRI Center, LLC License No.: 600-526-1 

Type of Action: New Amendment No.: 0 

Date Issued: 1/22/10 License Reviewer: LM 

File No.: 21 

Licensee: Reston Hospital Center License No.: 059-173-1 

Type of Action: Amendment Amendment No.: 3 

Date Issued: 10/15/10 License Reviewer: BS 

File No.: 22 

Licensee: Sentara Hospitals License No.: 650-187-1 

Type of Action: Amendment Amendment No.: 7 

Date Issued: 10/26/10 License Reviewer: BS 

File No.: 23 

Licensee: Wilbur Smith Associates License No.: 740-446-1 

Type of Action: Termination Amendment No.: 1 

Date Issued: 9/30/10 License Reviewer: BS 

File No.: 24 

Licensee: Washington & Lee University License No.: 678-228-1 

Type of Action: Renewal Amendment No.: 1 

Date Issued: 10/28/10 License Reviewer: BS 

File No.: 25 

Licensee: Selma Medical Associates, Inc. License No.: 840-186-1 

Type of Action: Renewal Amendment No.: 1 

Date Issued: 10/26/10 License Reviewer: BS 

File No.: 26 

Licensee: Cardinal Health Nuclear Pharmacy Services License No.: 740-034-1 

Type of Action: Amendment Amendment No.: Initial Conversion 

Date Issued: 5/4/10 License Reviewer: BS 

 
Virginia Final Report Page D.4 

License Casework Reviews 

File No.: 27 

Licensee: Martha Jefferson Hospital License No.: 540-137-1 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 12/7/09 License Reviewer: BS 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Virginia Commonwealth University License No.: General License 

Date of Incident: 2/27/09 NMED Log No.: 090472 

Investigation Date: 4/23/09 Type of Incident: Lost Source 

 Type of Investigation: Telephone 

File No.: 2 

Licensee: Best Medical International License No.: 059-018-1 

Date of Incident: 5/22/09 NMED Log No.: 090526 

Investigation Date: 6/1/09 Type of Incident: Lost Sources 

 Type of Investigation: Telephone 

File No.: 3 

Licensee: MACTEC Engineering & Consulting, Inc. License No.: 107-133-1 

Date of Incident: 8/14/09 NMED Log No.: 090675 

Investigation Date: 8/17/09 Type of Incident: Damaged Equipment 

 Type of Investigation: Site 

File No.: 4 

Licensee: Martha Jefferson Hospital License No.: 540-137-1 

Date of Incident: 9/30/09 NMED Log No.: 090754 

Investigation Date: 9/30/09 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

Comment: 

A site investigation was done during a routine inspection, one month later. 

File No.: 5 

Licensee: Virginia Department of Transportation License No.: 760-437-1 

Date of Incident: 3/30/10 NMED Log No.: 100153 

Investigation Date: 3/30/10 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: ECS Mid-Atlantic License No.: 170-314-1 

Date of Incident: 4/1/10 NMED Log No.: 100166 

Investigation Date: 4/2/10 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone 

 
Virginia Final Report Page E.2 

Incident Casework Reviews 

File No.: 7 

Licensee: Geotechnical Consulting and Testing License No.: 153-332-1 

Date of Incident: 4/23/10 NMED Log No.: 100239 

Investigation Date: 5/7/10 Type of Incident: Lost Sources 

 Type of Investigation: Site 

File No.: 8 

Licensee: Froehling & Robertson, Inc. License No.: 760-096-2 

Date of Incident: 2/27/10 NMED Log No.: 100267 

Investigation Date: 3/1/10 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone 

File No.: 9 

Licensee: Polymer Group, Inc. License No.: General License 

Date of Incident: 7/8/10 NMED Log No.: 100348 

Investigation Date: 7/9/10 Type of Incident: Lost Source 

 Type of Investigation: Site 

Comment: 

The investigation file was missing the Program’s response actions. 

File No.: 10 

Licensee: Polymer Group, Inc. License No.: General License 

Date of Incident: 7/9/10 NMED Log No.: 100349 

Investigation Date: 7/9/10 Type of Incident: Damaged Equipment 

 Type of Investigation: Site 

Comment: 

The investigation file was missing the Program’s response actions. 

File No.: 11 

Licensee: AMC Hoffman Center 22 License No.: General License 

Date of Incident: 7/2/10 NMED Log No.: 100364 

Investigation Date: 7/16/10 Type of Incident: Stolen Source 

 Type of Investigation: Telephone 
ATTACHMENT 

December 21, 2010 Letter from Maureen Dempsey, MD, FAAP 

Virginia’s Response to the Draft Report 

ADAMS Accession No.: ML103550430