FSME Procedure Approval 

Followup Integrated Materials Performance 

Evaluation Program (IMPEP) Reviews 

SA-119

Issue Date: August 24, 2012

Review Date: August 24, 2015 

Brian J. McDermott 

Director, MSSA /RA P. Henderson for/ Date: 08/24/2012 

A. Duncan White 

Branch Chief, MSSA /RA KSchneider for/ Date: 08/17/2012 

Michelle Beardsley 

Procedure Contact, MSSA /RA KSchneider for/ Date: 08/08/2012

ML12220A473

NOTE 

Any changes to the procedure will be the responsibility of the FSME Procedure Contact. 

Copies of the FSME procedures are available through the NRC website. 
 Procedure Title:

 Followup IMPEP Reviews 

 Procedure Number: SA-119

Page: 1 of 7 

Issue Date: 

08/24/2012

I. INTRODUCTION

Based on the findings of an Integrated Materials Performance Evaluation Program 

(IMPEP) review, the Management Review Board (MRB) may direct that a followup 

IMPEP review take place. This procedure describes the general objectives and process 

to be followed when conducting followup reviews of the U.S. Nuclear Regulatory 

Commission (NRC) Regional and Agreement State materials programs under IMPEP, 

including scheduling, assigning personnel, conducting and reporting the results of the 

reviews. The scope of the followup review will be dependent on the areas of the 

program identified as needing improvement. 

II. OBJECTIVES

A. To identify the appropriate individuals responsible for scheduling, conducting, and 

reporting the results of a followup review. 

B. To define the scope of activities and areas to be examined during a followup 

review. 

C. To define the methods and the timing for documenting and communicating the 

results of a followup review to Regional and Agreement State management and 

the MRB. 

III. BACKGROUND

The NRC Regional and Agreement State materials programs are reviewed at least every 

4 years under IMPEP, with the option to extend the frequency to 5 years for sustained 

performance. The MRB may direct that a followup review be conducted prior to the 

standard 4-year interval. A followup review may be scheduled at the direction of the 

MRB during or after a period of heightened oversight and will be conducted to evaluate 

the program=s response to previous IMPEP recommendations, and to evaluate the 

status of any indicator found “satisfactory, but needs improvement” or “unsatisfactory” 

during the last IMPEP review. A followup review can be used to track the progress of a 

program, and thus help determine the timing of the next IMPEP review and whether 

previous indicator findings should be changed and/or whether additional oversight may 

be needed. During each followup review, the team is also responsible for completing all 

elements of a Periodic Meeting as described in the Office of Federal and State Materials 

and Environmental Management Programs (FSME) Procedure SA-116. 

 
 SA-119: Followup IMPEP Reviews

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Issue Date: 

08/24/2012 

IV. ROLES AND RESPONSIBILITIES

FSME is the lead office responsible for coordination of Agreement State and NRC 

Regional followup IMPEP reviews. Additional information on roles and responsibilities 

can be found in FSME Procedure SA-100, Implementation of the Integrated Materials 

Performance Evaluation Program (IMPEP). 

A. MRB: 

1. Provides direction on the need for a followup review. This is usually 

determined from the results of a prior IMPEP review or Periodic Meeting. 

2. For followup reviews, the roles and responsibilities of the MRB and the 

guidelines to be followed by the MRB are the same as those detailed in 

FSME Procedure SA-106, The Management Review Board. 

3. Provides direction on a course of action to be taken when performance 

concerns are identified during the followup IMPEP review. 

B. Director, FSME: 

Acts as, or designates a FSME representative as an MRB member per FSME 

Procedure SA-106 and concurs on final followup IMPEP reports. 

C. Director, Division of Materials Safety and State Agreements (MSSA): 

1. Attends Agreement State and Regional IMPEP review exit meetings. 

2. Can designate the Deputy Division Director, MSSA, to attend IMPEP 

review exit meetings. 

D. Chief, Agreement State Program Branch (ASPB), FSME: 

 Transmits the proposed final report of followup reviews to the MRB. 

E. IMPEP Project Manager, MSSA: 

1. Reviews and provides feedback on all followup IMPEP reports to both the 

IMPEP team leader and FSME management. 

2. Coordinates MRB meetings per FSME Procedure SA-106, as necessary. 

3. Reviews each followup IMPEP report for consistency and adequate 

support of findings. 
 SA-119: Followup IMPEP Reviews

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Issue Date: 

08/24/2012 

F. IMPEP Team Leader: 

1. Schedules, coordinates and conducts assigned followup IMPEP reviews. 

2. Completes the IMPEP report in accordance with Management Directive 

(MD) 5.6, Integrated Materials Performance Evaluation Program (IMPEP), 

FSME Procedure SA-106, and this procedure. 

3. Designates an IMPEP team member to act as principal reviewer for each 

applicable performance indicator. 

4. Signs draft followup IMPEP reports issued to the Agreement State or 

Region. 

5. Presents review findings at MRB meetings. 

G. Regional State Agreements Officer (RSAO): 

1. Participates in all IMPEP followup reviews for Agreement States in their 

assigned Region when such a review is directed by the MRB. 

2. Completes the review of their assigned indicator(s) in accordance with the 

applicable FSME procedures and writes their assigned section(s) of the 

followup IMPEP report. 

3. Ensures the Periodic Meeting portion of the followup IMPEP review is 

completed and prepares the meeting summary, as necessary. 

4. Presents review findings at MRB meetings. 

H. IMPEP Team Member: 

1. Completes the review of their assigned indicator(s) in accordance with the 

applicable FSME procedure(s) and writes their assigned section(s) of the 

followup IMPEP report. 

2. Presents review findings at MRB meetings. 

V. GUIDANCE

A. Scope of Followup IMPEP Reviews: 

1. The followup review will include a complete review of one or more of the 

common and/or non-common performance indicators since the previous 

IMPEP review. Normally, these are indicators that resulted in findings of 
 SA-119: Followup IMPEP Reviews

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Issue Date: 

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Asatisfactory, but needs improvement@ or Aunsatisfactory@ during the 

previous IMPEP review. The review team will conduct an evaluation of 

the program=s response to previous IMPEP review recommendations 

dealing with these indicators. The team will recommend to the MRB 

whether these recommendations may be closed, remain open or 

modified. Additional recommendations for these indicators may also be 

developed during the followup review. 

2. During a followup IMPEP review, a Periodic Meeting will be performed 

following the meeting agenda in FSME Procedure SA-116, Periodic 

Meetings with Agreement States. The normal scheduling frequency for 

conducting Periodic Meetings outlined in SA-116 should not be followed. 

B. Assignment of Personnel for Followup IMPEP Reviews 

1. With the exception of the RSAO, team members should be different from 

those who conducted the previous IMPEP review. 

2. The criteria for selecting team members established in FSME Procedure 

SA-100 and MD 5.10, Formal Qualifications for Integrated Materials 

Performance Evaluation Program (IMPEP) Team Members should be 

followed. 

C. Scheduling Followup IMPEP Reviews 

Followup review scheduling should be completed along with routine scheduling 

as detailed in FSME Procedure SA-100 and should follow the time frame 

reflected in the previous final IMPEP report or as directed by the MRB. Followup 

reviews are normally performed approximately one year following the previous 

IMPEP review, Periodic Meeting or MRB meeting. 

D. Scheduling Letter and Review Questionnaire 

1. The team leader should send a letter to the Radiation Control Program 

Director or the NRC Regional Director, Division of Nuclear Materials 

Safety (DNMS) at least 90 days prior to the followup review. The letter 

should reference the discussion which established the review date, detail 

the dates of the program review, and request the Radiation Control 

Program Director or the Regional DNMS Director to schedule a closeout 

meeting of appropriate senior State managers or NRC Regional 

Administrator for the purpose of discussing the results of the review. 

a. The exit meeting should take place on the final day of the review. 

b. Copies of the letter should be sent to the team members, the 
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Issue Date: 

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IMPEP Project Manager, the ASPB Chief, the NRC Regional 

State Liaison Officer, the RSAO, and the Division Director, MSSA. 

2. The Team Leader and the IMPEP Project Manager should determine 

whether a questionnaire is necessary. If appropriate, the scheduling 

letter should include a current IMPEP questionnaire with instructions to 

address only those sections that apply. In addition to the printed version 

of the questionnaire, an electronic copy should also be provided. (See 

sample letters for Agreement State followup IMPEP reviews on the FSME 

website/IMPEP toolbox). 

E. Preparation for Followup IMPEP Reviews 

Guidance for review preparation can be found in FSME Procedure SA-100. 

F. Entrance Meeting 

Guidance for entrance meetings can be found in FSME Procedure SA-100. 

G. On-site Review 

1. Guidance for conducting the on-site portion of a review can be found in 

FSME Procedure SA-100. This guidance should be applied to only the 

specific indicators that are receiving a complete review. 

2. Guidance for conducting the other aspects of the followup review can be 

found in FSME Procedure SA-116. 

H. Third Party Attendance in Reviews 

Guidance for third party attendance, such as public or media representatives, at 

reviews can be found in FSME Procedure SA-100. 

I. Summarizing Review Findings 

Guidance for summarizing review findings can be found in FSME Procedure 

SA-100. 

J. Draft Reports 

1. Guidance for preparing the draft report can be found in FSME Procedure 

SA-100. 

2. See sample draft report transmittal letter and boiler plate draft Agreement 

State followup report on the FSME website/IMPEP toolbox. 
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Issue Date: 

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K. Proposed Final Reports, MRB Meetings, Final Reports, and Followup Actions 

1. Guidance for preparing and issuing the proposed/final reports and 

followup actions can be found in FSME Procedure SA-100. 

2. Guidance on conducting MRB Meetings can be found in FSME Procedure 

SA-106. 

3. See sample letters for Agreement State followup IMPEP reviews on the 

FSME website/IMPEP toolbox. 

VI. APPENDIX

Appendix A - Frequently Asked Questions 

VII. REFERENCES

1. NRC Management Directive 5.6, Integrated Materials Performance Evaluation 

Program. 

2. NRC Management Directive 5.10, Formal Qualifications for Integrated Materials 

Performance Evaluation Program (IMPEP) Team Members.

3. FSME Procedure SA-100, Implementation of the Integrated Materials 

Performance Evaluation Program (IMPEP).

4. FSME Procedure SA-106, The Management Review Board.

5. FSME Procedure SA-116, Periodic Meetings Between IMPEP Reviews. 

6. FSME Procedure SA-122, Heightened Oversight and Monitoring.

VII. ADAMS Reference Documents 

For knowledge management purposes, all previous revisions of this procedure, as well 

as associated correspondence with stakeholders, that have been entered into the NRC’s 

Agencywide Document Access Management System (ADAMS) are listed below. 
 SA-119: Followup IMPEP Reviews

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Issue Date: 

08/24/2012 

No. Date Document Title/Description Accession Number

1 11/7/02 STP-02-079, Opportunity to Comment on Draft 

Revisions to STP Procedure SA-119 ML023110511 

2 11/7/02 Memorandum to M.Virgilio et al re:Draft STP 

Procedure SA-119 

ML023110521 

3 11/7/02 Responses to STP-02-079 ML031740410 

4 4/4/03 Summary of Comments on SA-119 ML031710815 

5 4/4/03 STP Procedure SA-119, Followup IMPEP Reviews ML031080582 

6 2/22/07 FSME-07-020, Opportunity to Comment 5 

Procedures (including SA-119) 

ML070570341 

7 9/25/07 Summary of Comments on SA-119 ML072610485 

8 9/25/07 FSME Procedure SA-119, Followup IMPEP 

Reviews

ML072540828 

9 1/13/12 FSME-12-006, Opportunity to Comment on Draft 

Revision to FSME Procedure SA-119. 

ML113570269 
Appendix A

Frequently Asked Questions

Q: If I’m on the review team for a program that is to receive a followup review, will I 

automatically be on the followup review team? 

A: No. Original team members do not come back to participate on the followup review. 

Only the RSAO for the State is required to participate in the followup review for an 

Agreement State. New team members are appointed to participate in followup IMPEP 

reviews since this approach allows for unbiased perspectives on Program past or 

present performance issues. 

Q: Will a followup review always follow a period of Heightened Oversight? 

A: Generally, a followup review will follow a period of Heightened Oversight, although the 

findings of the followup review may not necessarily lead to the end of the Heightened 

Oversight period. 

Q: How long do I need to hold on to my IMPEP review materials once the review is over? 

A: Normally, we ask that team members retain their review materials only until the final 

report is issued. However, if a followup review is scheduled, team members should 

retain their materials until the followup review report has been issued. 

Q: What recommendations can be closed out during a followup review? 

A: Any recommendations from previous IMPEP reviews can be closed out if they are fully 

evaluated during a followup IMPEP review.