October 31, 2009 

Thomas Sieger, MS 

Deputy Administrator 

Division of Public Health 

Wisconsin Department of Health Services 

1 West Wilson Street, Room 250 

P. O. Box 2659 

Madison, WI 53701-2659 

Dear Mr. Sieger: 

On October 6, 2009, the Management Review Board (MRB) met to consider the proposed final 

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

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

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

Commission=s program. 

Section 5.0, page 10, 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 

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

meeting tentatively scheduled for July 2011. 

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: 

Wisconsin Final IMPEP Report 

cc w/encl.: See next page 
T. Sieger - 2 - 

cc w/encl: Charles Warzecha, Director 

 Bureau of Environmental 

 and Occupational Health 

 Paul Schmidt, Chief 

 Radiation Protection Division 

 Shawn Seeley, Maine 

 Organization of Agreement States 

 Liaison to the MRB 
October 31, 2009 

Thomas Sieger, MS 

Deputy Administrator 

Division of Public Health 

Wisconsin Department of Health Services 

1 West Wilson Street, Room 250 

P. O. Box 2659 

Madison, WI 53701-2659 

Dear Mr. Sieger: 

On October 6, 2009, the Management Review Board (MRB) met to consider the proposed final 

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

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

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

Commission=s program. 

Section 5.0, page 10, 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 

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

meeting tentatively scheduled for July 2011. 

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: 

Wisconsin Final IMPEP Report 

cc w/encl.: See next page 

Distribution: See next page.

 ML092800232 EDATS: FSME-2009-0037 

OFFICE FSME/MSSA FSME/MSSA FSME/MSSA FSME/MSSA 

NAME ATMcCraw:knm1 ADWhite TReis RJLewis 

DATE 10/07/09 10/13/09 10/13/09 10/14/09 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland GCPangburn MJVirgilio 

DATE 10/15/09 10/20/09 10/31/09 

OFFICIAL RECORD COPY
Letter to Thomas Sieger from Martin J. Virgilio dated: October 31, 2009 

Distribution: FSME-2009-0037 

MSSA RF DCD (SP01) 

EDO RF 

RidsFsmeOd Chairman Jaczko 

RidsSecyCorrespondenceMailCenter Commissioner Klein 

MBeardsley, FSME/MSSA Commissioner Svinicki 

JDeCicco, FSME/MSSA SECY 

JLynch, RIII/RSAO 

MLaFranzo, RIII 

James Harris, Kansas 

MFranovich, OEDO 

APowell, OCA (2 copies) 

JGray, OGC 

BJones, OGC 

CCasto, RIV 

TReis, FSME/MSSA 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE WSCONSIN AGREEMENT STATE PROGRAM 

JULY 13-17, 2009 

FINAL REPORT
Wisconsin Final Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of July 13-17, 2009, by a review team composed of 

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

Kansas. 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 August 26, 2005, to July 17, 2009, were discussed with 

Wisconsin managers on the last day of the review. 

A draft of this report was issued to Wisconsin for factual comment on August 6, 2009. The 

State responded by e-mail dated August 31, 2009, from Cheryl Rogers, Supervisor, Radioactive 

Materials Licensing and Inspection Unit. A copy of the State’s response is included as the 

Attachment to this report. The Management Review Board (MRB) met on October 6, 2009, to 

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

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

The Wisconsin Agreement State Program is administered by the Radiation Protection Section 

(the Section). The Section is part of the Bureau of Environmental and Occupational Health 

within the Division of Public Health (the Division). Organization charts for the State, the 

Department, and the Division are included as Appendix B. 

At the time of the review, the Wisconsin Agreement State Program regulated 330 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 Wisconsin. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Section on April 9, 2009. The Section provided 

its response to the questionnaire on June 11, 2009, with an update dated July 16, 2009. 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 

ML092180388. 

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

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

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

review of selected regulatory actions; (5) field accompaniments of four 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 Wisconsin Agreement State Program’s 

performance. 

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

during previous reviews. Results of the current review of the common performance indicators 
Wisconsin Final Report Page 2 

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable noncommon performance indicators, and Section 5.0 summarizes the review team's findings. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on August 25, 2005, the review team made 

no recommendations in regard to 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 Section’s staffing level and staff 

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

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

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

considered any workload backlogs. 

The Section, headed by the Section Chief, devotes approximately 9 full time equivalents (FTE) 

to the radioactive materials program, of which 5.8 are allotted for licensing and inspection. The 

remaining 3.2 FTE include program management, administrative support and a half-time 

training coordinator who assists the program with training needs. The training coordinator 

conducts in-house courses and coordinates participation in outside training courses. 

Since the last review, six individuals left the program, one of which transferred to a different 

position in the Section. During the review period, five new staff members were hired, three of 

which are still with the program. At the time of the review, the radioactive materials program 

had two vacancies. One position became vacant December 2008 and the other was a new 

position that was recently transferred to the Section. The position under which licensing and 

inspection efforts are hired is entitled Nuclear Engineer; after 3 years of experience, an 

individual is designated a Senior Nuclear Engineer. Currently, there are three Nuclear 

Engineers, and four Senior Nuclear Engineers in the Unit. Two recently hired staff members 

were not fully qualified to independently perform licensing or inspection activities at the time of 

the review; however, applications for required courses were submitted to complete their full 

qualification. 

The Section 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 Section also has on-the-job training to 

supplement the coursework so that individuals may broaden their work areas. Newer staff 

members are assigned increasingly complex licensing duties under the direction of the 

Radioactive Materials Licensing and Inspection Unit Supervisor (the Unit Supervisor) and 
Wisconsin Final Report Page 3 

accompany more experienced inspectors during increasingly complex inspections. Inspectors 

are assigned independent inspections after demonstrating competence during accompaniment 

evaluations by the Supervisor. The review team confirmed the qualifications of all staff through 

review of qualification journals, training records, and documentation of supervisory 

accompaniments. 

The review team noted that Section managers encourage and support training opportunities, 

based on program needs and funding. The review team concluded that the Section’s staffing 

and training is adequate to carry out its regulatory duties. 

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

that Wisconsin’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 Section’s questionnaire response relative to this indicator, data gathered from the 

Section’s database, examination of completed inspection casework, and interviews with the Unit 

Supervisor and staff members. 

The review team verified that Wisconsin’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.” Some categories of licenses were assigned inspection 

frequencies that prescribe a more frequent inspection schedule than those prescribed in IMC 

2800, such as remote afterloader units and nuclear pharmacies. 

The Section conducted a total of 251 inspections of Priority 1, 2, and 3 licensees during the 

review period. The review team identified 11 of these inspections that were conducted overdue 

by more than 25 percent of the inspection frequency prescribed by IMC 2800. The review team 

did not identify any inspections that were overdue at the time of the review. The review team 

also evaluated the Section’s timeliness for conducting initial inspections. The review team 

noted that the Section conducted 16 initial inspections during the review period, of which 2 were 

conducted greater than 12 months after license issuance. As required by IMC 2800, initial 

inspections should be conducted within 12 months of license issuance. One of the Section’s 

overdue initial inspections was conducted 3 months late; the other 1 month late. The review 

team verified that there were no overdue initial inspections at the time of the review. Overall, 

the review team calculated that the Section performed 6 percent of all Priority 1, 2, and 3 and 

initial inspections overdue during the review period. 

The Section has a policy of completing inspection reports within 30 days of the final date of the 

inspection. At the conclusion of each inspection, inspectors have the option to send inspection 

findings from the office or to issue a form similar to NRC’s Form 591 that can be left with the 

licensee at the conclusion of the inspection. The Section uses this form to document both clear 

inspections and inspections identifying infractions, deficiencies, or recommendations. The 

inspector can require a written response from the licensee describing corrective actions to 
Wisconsin Final Report Page 4 

address any infractions, deficiencies, or recommendations. The review team determined that 

inspection findings were usually issued within 30 days of the inspection. Of the 25 inspection 

files reviewed by the review team, one inspection summary was issued beyond the 30-day goal. 

During the review period, the Section received requests for reciprocity from 78 Priority 1, 2 and 

3 licensees, and performed inspections of 49 percent of those licensees. The Section 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 in each of the 4 years covered by the review 

period. 

The review team determined that the Section adequately planned for, and performed, the initial 

set of Increased Controls inspections of affected licensees. The review team evaluated the 

Section’s prioritization methodology and found it acceptable. The Section identified 27 

licensees that were subject to the Increased Controls and performed all of the initial inspections 

in a timely manner. The Section adequately evaluated the pertinent aspects of the security 

measures, including changes in licensee personnel or operations, during subsequent routine 

inspections of Increased Controls licensees. 

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

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

Program, was satisfactory. 

3.3 Technical Quality of Inspections

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

notes, and interviewed the responsible inspectors for 26 radioactive materials inspections 

conducted during the review period. The casework examined included a cross-section of 

inspections conducted by nine current and former inspectors and covered a wide variety of 

inspection types involving both initial and routine inspections. The casework included inspection 

of various types of programs, including: service providers, nuclear medicine, high dose-rate 

remote afterloader, medical broad scope, industrial radiography, self-shielded irradiator, gamma 

knife, portable gauge, reciprocity, and Increased Controls. Appendix C lists the inspection 

casework files reviewed and includes case-specific comments. 

Based on the evaluation of casework, the review team determined that, in almost all cases, 

inspections covered all aspects of the licensees’ radiation safety and security programs. The 

review team noted four instances, during reciprocity inspections, that the Increased Controls 

requirements were not fully evaluated to ensure licensee compliance with fundamental security 

aspects of the Increased Controls requirements. In interviews with the Unit Supervisor, the 

Supervisor provided an explanation regarding the lack of Increased Controls inspections, which 

included a lack of time, and dispatching inspectors that were not properly trained to inspect the 

licensees’ implementation of the Increased Controls. The Unit Supervisor indicated that more 

inspectors are being trained. The Unit Supervisor committed to reinforce expectations that will 

require aspects of the Increased Controls to be inspected, when possible. The review team 

verified that the Section is also reviewing aspects of the National Source Tracking System 

(NSTS) program. 
Wisconsin Final Report Page 5 

With the exception stated in the above paragraph, the review team noted 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 

Section requires licensees to respond to violations within 30 days of report issuance. Violations 

are considered the most severe type of finding and are usually only dispatched from the office 

after management review and approval. During the review of the Increased Controls inspection 

casework, the review team noted that the Section did not issue violations of the Increased 

Controls requirements. If deficiencies were identified during the first inspection, the Section 

performed several inspections of the same facility and followed up on those deficiencies until full 

compliance was achieved. For subsequent inspections, the Section issued violations if 

deficiencies were identified. 

While on site, the review team evaluated the Section’s handling and storing of sensitive 

information. The Section maintains two separate color-coded files for licensees subject to the 

Increased Controls: one that contains the routine licensing and inspection information and a 

second file that pertains to the inspection of the licensee’s implementation of the Increased 

Controls. The Section implemented this policy for better control of potential security-related 

information, as the second file is stored in a locked file cabinet. Documents observed were 

sufficiently marked as sensitive information to be withheld from public disclosure. 

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

an annual basis. The review team verified that the Unit Supervisor performed staff 

accompaniments annually of all staff performing materials inspections. A record of each 

accompaniment was noted on the inspection report and placed in the staff member’s training 

record. 

The review team verified that the Section 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. Instruments used to support the 

materials inspection program are sent to an authorized entity for calibration. The Section 

recently purchased a mobile laboratory that can be used for routine inspections or emergency 

events. 

The review team accompanied four of the Section’s inspectors in April and June 2009. The 

inspectors conducted inspections at a source material manufacturer, an industrial radiographer, 

a nuclear medicine clinic, and a research facility. The inspectors demonstrated appropriate 

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 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. 
Wisconsin Final Report Page 6 

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

that Wisconsin’s performance with respect to the indicator, Technical Quality of Inspection, was 

satisfactory. 

3.4 Technical Quality of Licensing Actions

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

licensing casework for 35 licensing actions for 21 specific licenses. 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 the 

license conditions, and overall technical quality. The review team also reviewed casework files 

for timeliness, use of appropriate deficiency letters and cover letters, reference to appropriate 

regulations, product certifications, supporting documentation, consideration of enforcement 

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

The review team selected licensing casework to provide a representative sample of licensing 

actions that were completed during the review period. Licensing actions selected for evaluation 

included 3 new licenses, 10 renewals, 20 amendments, and 2 license terminations. Files 

reviewed included a cross-section of license types, including: medical and academic broad 

scope, medical institution - limited, private practice, mobile nuclear medicine, nuclear pharmacy, 

permanent radiography, radiography - temporary jobsite, portable gauge, fixed gauge, and selfshielded irradiator. A listing of the licensing casework reviewed can be found in Appendix D. 

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

and of high quality with health, safety, and security issues properly addressed. License tiedown conditions were stated clearly, backed by information contained in the file, and were 

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

and identified substantive deficiencies in the licensees' documents. Terminated licensing 

actions were well documented, showing appropriate transfer and survey records. 

The administrative staff receives all licensing actions and enters all pertinent information into the 

Section’s database (named RAMPROD). The status of all actions is tracked by RAMPROD. 

The Supervisor assigns each action to one of seven reviewers based on workload and 

experience. For reviewers with less experience in a given area, the Supervisor provides 

additional oversight and/or assigns another experienced reviewer as a mentor. Deficiency 

letters are reviewed and signed by the reviewers. When the reviewer completes a licensing 

action, a second technical review is performed by another reviewer or the Supervisor. All 

completed actions are reviewed and signed by the Supervisor. The administrative staff 

conducts an administrative review and final processing before mailing out to the licensee. New 

and renewed licenses are issued for a 5-year term. After the 5-year term, licensees are 

required to submit a complete renewal application to maintain current information in the file. 

The Section uses templates to generate most correspondence and licenses, and there are 

standard formats and license conditions for each license type. The Section utilizes licensing 

guides based on NRC licensing guides (NUREG-1556 series), as appropriate, and maintains 

other licensing guidance (i.e., Technical Assistance Requests, regulatory guides) that are the 

same or similar to those used by NRC. 
Wisconsin Final Report Page 7 

The review team examined the Section’s licensing practices in regard to the Increased Controls 

and Fingerprinting requirements. The review team noted that the Section 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 Section’s methodology 

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

team verified that the Section has a process in place for identifying new or amended licenses 

that meet the criteria to implement the Increased Controls. 

The review team evaluated the Section’s efforts to impose the National Source Tracking System 

(NSTS) requirements on certain licensees. The Section amended affected licenses by adding 

legally binding license conditions, which were approved by NRC in September 2008. Most 

sealed source inventories were loaded into the system by the January 31, 2009 deadline. Staff 

demonstrated proficiency in using the NSTS database. 

The review team noted the use of a pre-licensing checklist and that the Section follows the 

implementation guidance provided in NRC’s Office of Federal and State Materials and 

Environmental Management Programs (FSME) Letter RCPD-08-020, dated September 22, 

2008, to enhance the basis for confidence that radioactive materials will be used as specified on 

a license. The review team observed that pre-licensing site visits were documented on the 

license review sheet. If a pre-licensing site visit was not required, the Section included a 

description of why a visit was not performed (e.g., the applicant was not a new entity or they 

were licensed in another state) on the license review sheet. 

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

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

Actions, was satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

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

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

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

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

casework for 21 of 48 reported radioactive materials incidents. A listing of the casework 

examined, with case-specific comments, can be found in Appendix E. The review team also 

evaluated the Section’s response to five allegations involving radioactive materials, including the 

two allegations that NRC forwarded to the State during the review period. 

When notified of an incident or an allegation, the Unit Supervisor and staff discuss the initial 

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

Section maintains a database for tracking the status of all incidents and allegations. If the 

incident meets the reportability thresholds, as established in the NRC’s Office of Federal and 

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

“Reporting Material Events,” the Section promptly notifies the NRC Headquarters Operations 

Center and NRC Region III. If the investigation is complex and extends over a period of time, 

NMED is appropriately updated, using the NMED software. Of the incidents evaluated by the 

review team, all had been reported to the NRC within the required time frame and been properly 

completed in NMED. 
Wisconsin Final Report Page 8 

The incidents selected for review included medical events, lost or stolen radioactive material, 

contamination events, a leaking source, a transportation event, and equipment failures. The 

review team determined that the Section’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 Section 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 Section determined that the licensee 

had qualified, competent individuals investigating the incident, the Section generally responded 

telephonically with an on-site follow-up inspection at a later date. The review team noted that at 

the conclusion of investigations, inspectors generated narrative reports that thoroughly 

documented the investigations. Records were stored in the Section’s license files and 

electronic filing system and were marked appropriately. 

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

evaluated the casework for five allegations. The review team concluded that the Section 

consistently took prompt and appropriate action in response to concerns raised. The review 

team noted that the Section thoroughly documented the investigations and retained all 

necessary documentation to appropriately close the allegations. The Section notified the 

allegers of the conclusion of the investigations. The review team determined that the Section 

adequately protected the identity of allegers. 

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

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

Allegation Activities, was satisfactory. 

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. NRC’s Agreement with the State of Wisconsin does not relinquish authority to 

evaluate sealed sources and devices or to regulate a low-level waste disposal site or uranium 

recovery activities, so only the first non-common performance indicator applied to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Wisconsin became an Agreement State on August 11, 2003. Legislative authority to create an 

agency is granted in Wisconsin Statute, Section 253.34; and the legislative authority to enter 

into an Agreement with NRC is granted in Wisconsin Statue, Section 254.335. Current effective 

legislation that affects the radiation control program is contained in Sections 254.31 through 

254.45. 

Chapter DHS 157, Wisconsin Administrative Code, details the licensing requirements and fees. 

DHS 157 is divided into 14 subchapters, relating to the regulation of radioactive materials and 

other sources of radiation. Along with their response to the questionnaire, the Section provided 
Wisconsin Final Report Page 9 

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

radiation control program. 

4.1.2 Program Elements Required for Compatibility 

The Wisconsin regulations governing radiation protection requirements are found in various 

subchapters of the Department of Health Services Section 157 of the Wisconsin Administrative 

Code. These rules apply to all ionizing radiation, whether emitted from radioactive materials or 

produced by machines. Section 254.365 of the Wisconsin Statures requires a license for the 

possession, use, manufacture, transport, storage or transfer of radioactive material. 

For each rulemaking initiative, Division staff develops a rulemaking plan that provides overview 

information (reason for rule changes, potential cost, stakeholder involvement, goals in 

completing rulemaking, etc), and details of the changes of the existing rule. The Division staff 

then submits all rulemaking documents, which include the rulemaking change language, to the 

Office of Legal Counsel for review. Upon completion of the Office of Legal Counsel review, the 

rulemaking document is submitted to the Office of the Secretary for release to the public for 

comment. At the time of publication for public comment, the Section sends the proposed rule to 

NRC for compatibility review. Regulatory action takes between 1 to 2 years to process and 

incorporate changes to DHS 157, the Chapter on Radiation Protection. The Section Chief is 

responsible for the entire radiation protection rule process. The Section has the authority to 

issue legally binding requirements (e.g., license conditions) in lieu of regulations until compatible 

regulations become effective. 

The review team evaluated Wisconsin’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. 

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 the on-site portion of the review, the following four amendments were overdue: 

• “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct 

Material,” 10 CFR Parts 30, 31, 32 amendment (65 FR 79162), that was due for 

Agreement State implementation on February 16, 2004. 

• “Compatibility with IAEA Transportation Safety Standards and Other Transportation 

Safety Amendments,” 10 CFR Part 71 amendment (69 FR 3697), that was due for 

Agreement State implementation on October 10, 2007. 

• “Medical Byproduct Material – Recognition of Specialty Boards,” 10 CFR Part 35 

amendment (70 FR 16336), that was due for Agreement State implementation on April 

29, 2008. 

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

15005), that was due for Agreement State implementation on March 27, 2009. 
Wisconsin Final Report Page 10 

Subsequent to the on-site portion of the review, the State completed a rulemaking package that 

addressed the four overdue regulation amendments and four other regulation amendments. 

With this package, the State is up to date on all NRC regulation amendments. The Section 

submitted the rulemaking package to NRC on August 27, 2009, for a compatibility review. NRC 

staff identified 15 comments that were transmitted to the State via letter on September 23, 2009. 

The following regulation amendment that will need to be addressed by the State in the future: 

• “Medical Use Of Byproduct Material – Authorized User Clarification,” 10 CFR Part 35 

amendment (72 FR 45147, 54207), that is due for Agreement State adoption by 

September 28, 2012. 

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

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

5.0 SUMMARY 

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

performance indicators reviewed. Overall, the review team recommended, and the MRB 

agreed, that the Wisconsin Agreement State Program is adequate to protect public health and 

safety and compatible with NRC's program. Based on the results of the current IMPEP review, 

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

in approximately 4 years.
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Wisconsin Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Attachment August 31, 2009 E-mail from Cheryl Rogers 

 Wisconsin’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Joseph DeCicco, FSME Team Leader 

 Compatibility Requirements 

James Harris, KS Technical Staffing and Training 

 Technical Quality of Licensing Actions 

James Lynch, Region III Status of Materials Inspection Program 

 Technical Quality of Incident and 

 Allegation Activities 

 Inspector Accompaniments 

Michael LaFranzo, Region III Technical Quality of Inspections 
APPENDIX B 

WISCONSIN ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML092100344
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Metaltek International License No.: 133-1181-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Dates: 3/27/07, 4/19/07, 7/18/07 Inspectors: PC, CR 

File No.: 2 

Licensee: Aurora Health Care Metro, Inc. License No.: 079-1281-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Dates: 6/12/07, 8/13/07 Inspector: JH 

File No.: 3 

Licensee: Great Lakes Testing, Inc. License No.: 009-1116-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Dates: 6/19-20/06, 8/31/06 Inspectors: MW, JH 

File No.: 4 

Licensee: Community Blood Center, Inc. License No.: 087-1067-01 

Inspection Type: Routine/Special, Unannounced Priority: 5 

Inspection Date: 10/4/06 Inspectors: JH, PC 

File No.: 5 

Licensee: Shaw Pipeline Services, Inc. License No.: 035-1236-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Date: 6/27/08 Inspectors: CR, CD 

File No.: 6 

Licensee: Metaltek International License No.: 133-1181-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/8/09 Inspector: KP 

File No.: 7 

Licensee: Conam Inspections License No.: NRC 12-16559-02 

Inspection Type: Reciprocity, Initial Priority: 1 

Inspection Date: 7/13/06 Inspectors: MW, MM 
Wisconsin Final Report Page C.2

Inspection Casework Reviews 

File No.: 8 

Licensee: Great Lakes Testing License No.: 009-1116-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/9/08 Inspector: PC 

File No.: 9 

Licensee: Cardinal Health License No.: 141-1306-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 11/26/08 Inspectors: CT, JH 

File No.: 10 

Licensee: Mercy Hospital License No.: 105-1176-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 1/29/09 Inspectors: DS, JH 

File No.: 11 

Licensee: Lafayette Testing Services License No.: 079-1147-01 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/1/08 Inspector: PJC 

File No.: 12 

Licensee: Aurora Health Care Southern Lakes, Inc. License No.: 127-1023-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/3/08 Inspector: JH 

File No.: 13 

Licensee: CERAC, Inc. License No.: 079-1055-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/9/09 Inspector: MS 

File No.: 14 

Licensee: St. Michael’s Hospital License No.: 097-1301-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 7/6/09 Inspector: LD 

File No.: 15 

Licensee: Team Industrial Services License No.: 079-2005-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 1/31/07 Inspector: MM 

File No.: 16 

Licensee: Wisconsin Medical Cyclotron License No.: 079-1366-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 3/14/08 Inspector: RS 
Wisconsin Final Report Page C.3

Inspection Casework Reviews 

File No.: 17 

Licensee: Dane Co. Sanitary Landfill Site No. 2 License No.: 025-1082-01 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 7/11/07 Inspector: SM 

File No.: 18 

Licensee: Varian Medical Systems License No.: 45-30957-01 

Inspection Type: Reciprocity. Announced Priority: 1 

Inspection Date: 5/11/09 Inspector: DS 

File No.: 19 

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

Inspection Type: Reciprocity, Announced Priority: 3 

Inspection Date: 5/25/07 Inspector: RS 

File No.: 20 

Licensee: JANX License No.: 21-16560-01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 7/16/08 Inspector: KP 

File No.: 21 

Licensee: JANX License No.: 21-16560-01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 4/23/07 Inspector: MM 

File No.: 22 

Licensee: Dean Medical Center License No.: 025-1083-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/22/06 Inspector: MW 

File No.: 23 

Licensee: St. Mary’s Hospital License No.: 025-1293-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/4/07 Inspector: RS 

File No.: 24 

Licensee: AITEC USA Investments, Inc. License No.: TX L05718 

Inspection Type: Reciprocity, Announced Priority: 1 

Inspection Date: 4/4/07 Inspector: MM 

File No.: 25 

Licensee: Seaman Nuclear Corporation License No.: 079-1257-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 1/29/08 Inspectors: MS, PC 
Wisconsin Final Report Page C.4

Inspection Casework Reviews 

File No.: 26 

Licensee: University of Wisconsin License No.: 025-1323-01 

 Madison Safety Department 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Dates: 11/13-20/07 Inspectors: MS, LD, JH, SM 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Molecular Biology Resources, Inc. License No.: 079-1195-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 4/27/09 Inspector: CT 

Accompaniment No.: 2 

Licensee: Wheaton Franciscan Medical Group, Inc. License No.: 079-1352-01 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 4/28/09 Inspector: DS 

Accompaniment No.: 3 

Licensee: MetalTek International License No.: 133-1181-01 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 6/8/09 Inspector: KP 

Accompaniment No.: 4 

Licensee: CERAC, Inc. License No.: 079-1055-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/9/09 Inspector: MS 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Great Lakes Testing License No.: 009-1116-01 

Type of Actions: Renewal, Amendment Amendment Nos.: 04, 05, 06 

Dates Issued: 5/12/08, 11/14/08, 12/10/08 License Reviewer: MS 

File No.: 2 

Licensee: Community Blood Center License No.: 087-1067-01 

Types of Action: Renewal, Amendment Amendment Nos.: 03, 04, 05, 06 

Dates Issued: 10/09/07, 5/12/08, 11/14/08, 12/23/08 License Reviewers: LD,MS 

File No.: 3 

Licensee: Aurora Health Care Metro License No.: 079-1281-01 

Type of Action: Amendment Amendment Nos.: 08, 14 

Dates Issued: 9/30/05, 12/22/08 License Reviewers: PC, LD 

File No.: 4 

Licensee: Shaw Pipeline Service License No.: 035-1236-01 

Type of Action: New Amendment No.: 0 

Date Issued: 12/18/07 License Reviewer: KP 

File No.: 5 

Licensee: BayCare Clinic License No.: 139-1309-01 

Types of Action: Renewal, Amendment Amendment Nos.: 02, 03 

Dates Issued: 11/5/07, 5/29/09 License Reviewers: KP, LD 

File No.: 6 

Licensee: Appleton Medical Center License No.: 087-1014-01 

Type of Action: Amendment Amendment Nos.: 06, 08, 12 

Dates Issued: 10/14/05, 10/27/06, 10/6/08 License Reviewers: MW, RS, MS 

File No.: 7 

Licensee: Northern Shared Medical Service License No.: 025-1209-01 

Type of Action: Amendment Amendment Nos.: 24, 30, 31 

Dates Issued: 1/22/07, 7/1/08, 4/1/09 License Reviewers: RS, JH, DS 

File No.: 8 

Licensee: Community Memorial Hospital License No.: 133-1069-01 

Types of Action: Renewal, Amendment Amendment Nos.: 16, 17 

Dates Issued: 12/12/08, 1/21/09 License Reviewer: DS 
Wisconsin Final Report Page D.2 

License Casework Reviews 

File No.: 9 

Licensee: ECS Illinois License No.: 105-1221-01 

Type of Action: New Amendment No.: 0 

Date Issued: 2/4/08 License Reviewer: KP 

File No.: 10 

Licensee: Community Memorial Hospital License No.: 083-1068-01 

Type of Action: Renewal Amendment No.: 01 

Date Issued: 2/7/07 License Reviewer: MS 

File No.: 11 

Licensee: Chosen Valley Testing License No.: 063-2009-01 

Type of Action: Amendment Amendment No.: 04 

Date Issued: 5/19/08 License Reviewer: LD 

File No.: 12 

Licensee: CGC License No.: 025-1056-01 

Type of Action: Renewal, Amendment Amendment Nos.: 06, 07 

Dates Issued: 2/28/08, 9/24/08 License Reviewers: MW, PC 

File No.: 13 

Licensee: Standard Imaging License No.: 025-1304-01 

Type of Action: Amendment Amendment No.: 06 

Date Issued: 12/17/07 License Reviewer: LD 

File No.: 14 

Licensee: Ripon College License No.: 039-1240-01 

Type of Action: Termination Amendment No.: 02 

Date Issued: 7/19/06 License Reviewer: MW 

File No.: 15 

Licensee: Medi-Physics License No.: 079-1168-01 

Type of Action: Amendment Amendment Nos.: 09, 18 

Dates Issued: 5/29/07, 3/4/09 License Reviewer: LD 

File No.: 16 

Licensee: Kenosha County Div. of Health License No.: 059-1140-01 

Type of Action: Renewal Amendment No.: 04 

Date Issued: 8/13/08 License Reviewer: KP 

File No.: 17 

Licensee: Domtar A.W. License No.: 141-1086-01 

Type of Action: Renewal Amendment No.: 04 

Date Issued: 6/29/09 License Reviewer: CT 
Wisconsin Final Report Page D.3 

License Casework Reviews 

File No.: 18 

Licensee: Community Housing Initiative License No.: 133-1098-01 

Type of Action: Termination Amendment No.: 03 

Date Issued: 12/6/07 License Reviewer: KP 

File No.: 19 

Licensee: The Wisconsin Heart Hospital License No.: 079-1359-01 

Type of Action: Renewal Amendment No.: 05 

Date Issued: 1/29/09 License Reviewer: CT 

File No.: 20 

Licensee: R H Batterman & Co. License No.: 105-1233-01 

Type of Action: Renewal Amendment No.: 05 

Date Issued: 1/21/09 License Reviewer: CT 

File No.: 21 

Licensee: Road Runner Consulting License No.: 025-1336-01 

Type of Action: New Amendment No.: 0 

Date Issued: 7/17/07 License Reviewer: SM 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Cardinal Health License No.: 079-1311-01 

Date of Incident: 2/24/06 NMED Log No.: 060172 

Investigation Date: 2/27/06 Type of Incident: Contamination Event 

 Type of Investigation: Telephone 

File No.: 2 

Licensee: Cardinal Health License No.: 079-1311-01 

Date of Incident: 3/3/06 NMED Log No.: 060175 

Investigation Date: 3/9/06 Type of Incident: Contamination Event 

 Type of Investigation: Telephone 

File No.: 3 

Licensee: Elmbrook Memorial Hospital License No.: 079-1092-01 

Date of Incident: 5/16/06 NMED Log No.: 060610 

Investigation Date: 5/17/06 Type of Incident: Lost Sources 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: University of Wisconsin License No.: 025-1323-01 

Date of Incident: 12/27/06 NMED Log No.: 070015 

Investigation Date: 1/8/07 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 5 

Licensee: Bristol-Myers Squibb Medical Imaging License No.: Non-licensee 

Date of Incident: 1/14/07 NMED Log No.: 070027 

Investigation Date: 1/17/07 Type of Incident: Lost Sources 

 Type of Investigation: Site 

File No.: 6 

Licensee: Miller Compressing License No.: Non-licensee 

Date of Incident: 2/22/07 NMED Log No.: 070132 

Investigation Date: 2/22/07 Type of Incident: Lost Sources 

 Type of Investigation: Telephone 

File No.: 7 

Licensee: Saint Vincent Hospital License No.: 09-1303-01 

Date of Incident: 4/4/07 NMED Log No.: 070211 

Investigation Date: 4/6/07 Type of Incident: Medical Event 

 Type of Investigation: Site 
Wisconsin Final Report Page E.2 

Incident Casework Reviews 

File No.: 8 

Licensee: Roofing Consultants, Ltd. License No.: Non-license 

Date of Incident: 4/24/07 NMED Log No.: 070250 

Investigation Date: 4/24/07 Type of Incident: Stolen Sources 

 Type of Investigation: Telephone 

File No.: 9 

Licensee: Aurora Saint Luke’s Medical Center License No.: 079-1281-01 

Date of Incident: 5/31/07 NMED Log No.: 070350 

Investigation Date: 5/31/07 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 10 

Licensee: Wheaton Franciscan Healthcare-St. Francis License No.: 079-1285-01 

Date of Incident: 8/28/07 NMED Log No.: 070562 

Investigation Date: 8/28/07 Type of Incident: Lost Source 

 Type of Investigation: Telephone 

File No.: 11 

Licensee: Wheaton Franciscan Healthcare-St. Francis License No.: 079-1285-01 

Date of Incident: 9/19/07 NMED Log No.: 070689 

Investigation Date: 9/21/07 Type of Incident: Leaking Source 

 Type of Investigation: Site 

File No.: 12 

Licensee: Aurora Saint Luke’s Medical Center License No.: 079-1281-01 

Date of Incident: 1/31/08 NMED Log No.: 080070 

Investigation Date: 1/31/08 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

Comment: 

 The Section did not perform a reactive inspection, as planned. 

File No.: 13 

Licensee: Marshfield Clinic Minocqua Center License No.: 141-1162-01 

Date of Incident: 3/4/08 NMED Log No.: 080144 

Investigation Date: 3/4/08 Type of Incident: Lost Sources 

 Type of Investigation: Telephone 

File No.: 14 

Licensee: Appleton Medical Center License No.: 087-1014-01 

Date of Incident: 3/6/08 NMED Log No.: 080156 

Investigation Date: 3/17/08 Type of Incident: Medical Event 

 Type of Investigation: Site 
Wisconsin Final Report Page E.3 

Incident Casework Reviews 

File No.: 15 

Licensee: Team Industrial Services, Inc. License No.: 079-2005-01 

Date of Incident: 4/15/08 NMED Log No.: 080238 

Investigation Date: 5/22/08 Type of Incident: Equipment Failure 

 Type of Investigation: Site 

File No.: 16 

Licensee: University of Wisconsin License No.: 025-1323-01 

Date of Incident: 7/14/08 NMED Log No.: 080406 

Investigation Date: 7/17/08 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 17 

Licensee: University of Wisconsin License No.: 025-1323-01 

Date of Incident: 8/18/08 NMED Log No.: 080493 

Investigation Date: 8/20/08 Type of Incident: Contamination Event 

 Type of Investigation: Site 

File No.: 18 

Licensee: GE Healthcare License No.: Non-licensee 

Date of Incident: 12/15/08 NMED Log No.: 090156 

Investigation Date: 12/15/08 Type of Incident: Contaminated Equipment 

 Type of Investigation: Telephone 

File No.: 19 

Licensee: Aurora Health Care Central License No.: 117-1022-01 

Date of Incident: 3/9/09 NMED Log No.: 090385 

Investigation Date: 3/12/09 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 20 

Licensee: University of Wisconsin License No.: 025-1323-01 

Date of Incident: 3/18/09 NMED Log No.: 090398 

Investigation Date: 3/20/09 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 21 

Licensee: Wheaton Franciscan Healthcare-St. Joseph License No.: 079-1288-01 

Date of Incident: 6/25/09 NMED Log No.: 090571 

Investigation Date: 6/29/09 Type of Incident: Medical Event 

 Type of Investigation: Site 
ATTACHMENT 

August 31, 2009 E-mail from Cheryl Rogers 

Wisconsin’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML092600596