December 16, 2013 

Suzanne Hoffman, Interim Director 

Oregon Public Health Division 

Department of Health and Human Services 

800 NE Oregon Street, Suite 640 

Portland, OR 97232 

Dear Ms. Hoffman: 

On October 29, 2013, the Management Review Board (MRB) met to consider the proposed final 

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

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

health and safety, and compatible with the U.S. Nuclear Regulatory Commission’s program. 

Section 5.0, page 12, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. Four of six performance indicators reviewed were found 

satisfactory. The indicators Technical Quality of Licensing Actions and Technical Quality of 

Incidents and Allegation Activities were found satisfactory, but need improvement. The review 

team made five new recommendations during this review in regard to program performance, 

and kept one recommendation open from the 2009 review. Based on the results of the current 

IMPEP review, the next full review of the Oregon Agreement State Program will take place in 

approximately 4 years, with a periodic meeting tentatively scheduled for August 2015. The 

corrective actions taken to address the open recommendations will be reviewed during the 

periodic meeting and subsequently verified for closure at the next IMPEP. No additional written 

response is required at this time to address the open recommendations.

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: 

Oregon Final IMPEP Report 

cc w/ encl: David M. Howe, Program Director 

Radiation Protection Services Section 

Oregon Health Authority 

Robert Greger, California 

Organization of Agreement States 

 Liaison to the MRB
Suzanne Hoffman, Interim Director 

Oregon Public Health Division 

Department of Health and Human Services 

800 NE Oregon Street, Suite 640 

Portland, OR 97232 

Dear Ms. Hoffman: 

On October 29, 2013, the Management Review Board (MRB) met to consider the proposed final 

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

Program. The MRB found the Oregon program adequate to protect public health and safety, and 

compatible with the U.S. Nuclear Regulatory Commission’s program. 

Section 5.0, page 12, of the enclosed final report contains a summary of the IMPEP team’s findings and 

recommendations. Four of six performance indicators reviewed were found satisfactory. The indicators 

Technical Quality of Licensing Actions and Technical Quality of Incidents and Allegation Activities were 

found satisfactory, but need improvement. The review team made five new recommendations during this 

review in regard to program performance, and kept one recommendation open from the 2009 review. 

Based on the results of the current IMPEP review, the next full review of the Oregon Agreement State 

Program will take place in approximately 4 years, with a periodic meeting tentatively scheduled for August 

2015. The corrective actions taken to address the open recommendations will be reviewed during the 

periodic meeting and subsequently verified for closure at the next IMPEP. No additional written response 

is required at this time to address the open recommendations. 

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: 

Oregon Final IMPEP Report 

cc w/ encl: David M. Howe, Program Director 

Radiation Protection Services Section 

Oregon Health Authority 

Robert Greger, California 

Organization of Agreement States 

 Liaison to the MRB

DISTRIBUTION: 

See next page 

 ML13308A201 

OFC Region I: TL ASPB/MSSA ASPB:BC MSSA: D TechEd FSME:D EDO/DEDMRT 

NAME MFord via email LDimmick LCD DWhite 

ADW 

PHenderson 

(CE for) 

CPoland 

(PMT for) 

BHolian MWeber 

DATE 11/04/13 11/04/13 11/05/13 11/18/13 11/20/13 11/25/13 12/16/13 

OFFICIAL RECORD COPY 
Letter to S. Hoffman from Michael F. Weber dated December 16, 2013 

SUBJECT: OREGON FY2013 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

RidsEdoMailCenter 

JFoster, OEDO 

RidsFsmeOd 

RidsOgcMailCenter 

ABoland, RIII 

RidsRgn4MailCenter 

SReynolds, RIV 

AVegel, RIV 

VCampbell, RIV 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

RidsFsmeMssa Commissioner Svinicki 

BTharakan, RIV Commissioner Apostolakis 

RErickson, RIV/RSAO Commissioner Magwood 

BGortzki, AZ Commissioner Ostendorff 

TCarpenter, OR SECY 

RWendt, OR 

JWeil, OCA (2 copies) 

 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE OREGON AGREEMENT STATE PROGRAM 

AUGUST 12–16, 2013 

FINAL REPORT
EXECUTIVE SUMMARY 

This report presents the results of the Integrated Materials Performance Evaluation Program 

(IMPEP) review of the Oregon Agreement State Program. The review was conducted during 

the period of August 12–16, 2013, by a review team composed of technical staff members from 

the U.S. Nuclear Regulatory Commission (NRC) and the State of Arizona.

Based on the results of this review, Oregon’s performance was found satisfactory for the 

indicators Technical Staffing and Training, Status of Materials Inspection Program, Technical 

Quality of Inspection, and Compatibility Requirements and satisfactory, but needs improvement 

for the indicators Technical Quality of Licensing Actions and Technical Quality of Incidents and 

Allegation Activities. The finding of satisfactory but needs improvement for the indicators 

Technical Quality of Incident and Allegation Activities and Technical Quality of Licensing Actions 

remains the same from the 2009 IMPEP report and the finding of satisfactory for the indicator 

Technical Quality of Inspections is an improvement from the 2009 IMPEP report. 

The review team made a total of five recommendations in the indicators Technical Quality of 

Licensing Actions, Technical Quality of Incident and Allegation Activities, and Compatibility 

Requirements. The review team closed two recommendations from the 2009 IMPEP report and 

kept one recommendation open. The open recommendation is in the indicator Technical 

Quality of Incident and Allegation Activities. 

Accordingly, the review team recommended, and the Management Review Board (MRB) 

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

safety and is compatible with the NRC's program. The review team recommended, and the 

MRB agreed, that the next IMPEP review take place in approximately four years. 
Oregon Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of August 12–16, 2013, by a review team composed of 

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

Arizona. 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 28, 2009 to August 16, 2013, were discussed with 

Oregon managers on the last day of the review. 

A draft of this report was provided to Oregon for factual comment on September 11, 2013. The 

State responded by letter dated October 14, 2013. A copy of the State’s response is included 

as an Attachment to this report. A Management Review Board (MRB) met on October 29, 2013, 

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

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

The Oregon Agreement State Program is administered by the Radiation Protection Services 

Section (the Section), which is located within the Center for Health Protection (the Center). The 

Center is part of the Oregon Public Health Division (the Division). Organization charts for the 

Section, the Center, and the Division are included as Appendix B. 

At the time of the review, the Oregon Agreement State Program regulated 315 specific licenses 

authorizing possession and use of radioactive 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 State of Oregon. 

In preparation for the review, a questionnaire addressing the common and applicable 

non-common performance indicators was sent to the Section on May 16, 2013. The Section 

provided its response to the questionnaire on July 25, 2013. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML13206A271. 

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 Oregon statutes and 

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

review of selected regulatory actions, (5) field accompaniments of two 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 Oregon Agreement State Program’s 

performance. 

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

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

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable 

non-common performance indicators, and Section 5.0 summarizes the review team's findings. 
Oregon Final IMPEP Report Page 2 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on August 27, 2009, the review team made 

three recommendations regarding the Oregon Agreement State Program’s performance. The 

status of each open recommendation is as follows: 

1. “The review team recommends the State develop and use a documented formal 

qualification program (including refresher training) for inspection and licensing staff 

that would include journals that clearly indicate each individual’s training and 

qualification including oral and/or written evaluation of their understanding of 

regulations and guidance documents.” 

 

Status: The Section developed and utilizes a formal qualification program for all new 

licensing and inspection staff which clearly indicates each individuals training and 

qualification and their understanding of regulations and guidance. The Section 

separately tracks and utilizes refresher/continuing education training for its qualified 

inspection and licensing staff. This recommendation is closed. 

2. “The review team recommends that the State develop and implement a procedure 

for the control of sensitive or security-related information that provides guidance to 

identify, mark, handle, and protect such information.” 

Status: The Section developed and implemented a protocol for the identification, 

marking, handling, control and protection of sensitive security-related information. 

Each member of the staff and management was involved in the development and 

implementation of the protocol. This recommendation is closed. 

3. “The review team recommends that the Section implement a process to ensure all 

required information is submitted to the NRC’s Nuclear Materials Events Database 

(NMED) and to also promote timely completion of NMED entries.” 

Status: The Section modified its protocol for incident and allegation activities to 

ensure that all of the required information be submitted to NMED and that entries 

were completed in a timely manner. The review team determined that out of the 

seven events that were reported to NMED, four of the incidents were not submitted 

to the NRC in a timely manner in accordance with the Handbook on Nuclear Material 

Event Reporting in the Office of Federal and State Materials and Environmental 

Management Programs (FSME) Procedure SA-300, Reporting Material Events and 

six incidents did not contain complete and accurate information in NMED. Therefore, 

the review team determined that the recommendation be kept open until the Section 

has had an opportunity to review incidents reported to NMED and close the incidents 

as appropriate, as well as, ensure that the process is consistently implemented for 

each incident. This recommendation remains open. 

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, 
Oregon Final IMPEP Report Page 3 

(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

Considerations central to the evaluation of this indicator include the Section’s staffing level and 

staff turnover, as well as the technical qualifications and training history 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 workload backlogs. 

The Section, which is supervised by the Section Manager, is divided into two units: the 

Emergency Preparedness, Licensing & Administration Unit and the Emergency Response, 

Field Operations & Technical Services Unit. The Section is responsible for licensing, 

inspection, training, and emergency preparedness and response activities for radioactive 

materials facilities. At the time of the review, there were eight technical staff members and 

managers in the Section with various degrees of involvement in the radioactive materials 

program, totaling approximately 6.5 full-time equivalents (FTE). 

Since the 2009 IMPEP review, three individuals, two technical staff and the Section Manager 

left the radioactive materials program. These individuals left in December 2010, February 

2012, and January 2011 respectively. The Emergency Response, Field Operations, & 

Technical Services Manager was promoted in January 2011 to the Section Manager position. 

The Section hired a new Emergency Response, Field Operations, & Technical Services 

Manager in September of 2011. The Section also hired one new technical staff in May 2011 

and transferred an individual from another area of the Section to radioactive materials in 

January 2013. No positions were vacant at the time of the review and no backlogs occurred 

in licensing or inspection actions due to the staff turnover. The Section has one administrative 

assistant which is adequate for the level of work generated. The review team determined that 

staffing levels were adequate for the Oregon Agreement State program. 

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.” Staff members are assigned increasingly 

complex duties as they progress through the qualification process. The new staff received the 

training plan and uses it to complete the requirements to become fully qualified license 

reviewers and inspectors. The review team concluded that the Section’s training program is 

adequate to carry out its regulatory duties and noted that management supports the training 

program. 

Oregon Revised Statue 453.645 states that the Director of the Oregon Health Authority shall 

appoint a Radiation Advisory Committee consisting of eight members representing various 

disciplines within the radiation industry. The Radiation Advisory Committee meets every four 

months and provides advice on radiation protection issues and regulations. The Radiation 

Advisory Committee has no oversight authority. The review team identified no potential conflicts 

of interest. 
Oregon Final IMPEP Report Page 4 

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

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

found 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 

management and staff. 

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

material licenses are at least as frequent as or in some cases more frequent than similar license 

types listed in IMC 2800, “Materials Inspection Program.” There are 83 license categories 

established by the Section. The Section assigned inspection priority codes that prescribe a 

more frequent inspection schedule than those established in IMC 2800 for similar license types 

for 43 categories. 

The Section conducted 126 Priority 1, 2, and 3 inspections during the review period, based on 

the inspection frequencies established in IMC 2800. Three of these inspections were conducted 

overdue by more than 25 percent of the inspection frequency prescribed in IMC 2800. In 

addition, the Section performed four initial inspections during the review period, none of which 

were conducted overdue. As required by IMC 2800, initial inspections were conducted within 12 

months of license issuance. Overall, the review team calculated that the Section performed 2.3 

percent of its inspections overdue during the review period. 

The review team evaluated the Section’s timeliness in providing inspection findings to licensees. 

A sampling of 27 inspection reports indicated that one of the inspection findings reviewed was 

communicated to the licensee beyond the Section’s goal of 30 days after the inspection. The 

late inspection finding was issued three months after the inspection date. The review team 

determined that the Section was timely in its issuance of inspection findings to its licensees. 

During the review period, the Section granted 53 reciprocity permits, 42 of which were candidate 

licensees based upon the criteria in IMC 1220, “Processing of NRC Form 241 and Inspection of 

Agreement State Licensees Operating under 10 CFR 150.20.” The review team determined 

that the Section exceeded the NRC’s criteria of inspecting 20 percent of candidate licensees 

operating under reciprocity in three of the four years covered by the review period. The Section 

did not meet NRC’s criteria of inspecting 20 percent of candidate licensees operating under 

reciprocity in calendar year 2011. 

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

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

be found satisfactory. 
Oregon Final IMPEP Report Page 5 

3.3 Technical Quality of Inspections

The review team evaluated the inspection reports, enforcement documentation, inspection field 

notes, and interviewed inspectors for 27 radioactive materials inspections conducted by the 

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

one former and three current Section inspectors and covered inspections of various license 

types: industrial radiography including both field and fixed sites, industrial, academic and 

medical broad scope licenses, medical institutions including high dose rate remote after-loader, 

nuclear pharmacy, self-shielded irradiators, gamma knife, mobile nuclear medicine including 

mobile Positron Emission Tomography imaging, source material, and the State’s own license for 

impounded materials. The casework reviewed included both initial and follow-up inspections as 

well as Increased Controls (IC) inspections. Appendix C lists the inspection casework files 

reviewed as well as the results of the inspector accompaniments. 

Based on the evaluation of the casework, the review team noted that inspections covered all 

aspects of the licensee’s radiation safety programs. The review team found that inspection 

reports reviewed were thorough, complete, consistent, and of high quality, with sufficient 

documentation to ensure that a licensee’s performance with respect to health, safety and 

security was acceptable. The documentation supported violations, recommendations made to 

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

The inspection protocols utilized by the Section are consistent with the inspection guidance 

outlined in IMC 2800. Inspection findings including any violations are documented on Oregon 

Form 591 and provided to the licensee at the conclusion of the inspection. For inspections 

where staff is unable to complete the inspection on site because they are waiting on additional 

information from the licensee to complete an inspection, findings are documented by letter and 

dispatched to the licensee from the office. 

The review team noted that the Section has an adequate supply of survey instruments to 

support the Section’s inspection program. Calibrated survey instrumentation, such as 

Geiger-Mueller meters, scintillation detectors, ion chambers, micro-R meters, multi-channel 

analyzers and neutron detectors were available for use for inspections or for emergency 

response operations as needed. Instruments are calibrated by an Oregon calibration lab with 

National Institute of Standards and Technology traceable sources. The Section tracks each 

instrument, its current location, and next calibration date. The Section also analyzes 

radiological samples in its own laboratory which has a wide variety of analytical equipment 

capable of detailed radiological analysis. Staff members have been trained to operate the 

equipment and perform the analysis as needed. 

The Section reported that supervisor accompaniments were not performed in 2010. This 

occurred during transitions in Section management; however accompaniments were properly 

performed in years 2011-2013. In one instance a new inspector was accompanied by a senior 

inspector instead of a supervisor. The supervisory accompaniments are documented and 

maintained within the Section. 

Accompaniments of two Section inspectors were conducted on July 30, 2013, and July 31, 

2013. The inspectors were accompanied during health, safety and security inspections of 

an industrial radiography facility and a gamma knife. During each of the accompaniments, 
Oregon Final IMPEP Report Page 6 

the inspectors demonstrated appropriate inspection techniques, knowledge of the 

regulations, and conducted performance based inspections. The inspectors were trained, 

well-prepared for the inspection, 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 inspections were adequate to assess radiological health, 

safety, and security at each of the licensed facilities. 

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

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

found satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team examined completed casework and interviewed license reviewers for 32 

licensing actions covering 31 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, security requirements, operating and emergency procedures, 

appropriateness of license conditions, and overall technical quality. The casework was also 

reviewed for timeliness, use of appropriate correspondence, reference to appropriate 

regulations, supporting documentation, consideration of enforcement history, pre-licensing 

visits, peer and supervisory review, and proper signatures. 

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

during the review period. Licensing actions selected for evaluation included 3 new licenses, 6 

renewals, 19 amendments, and 3 license terminations. Casework reviewed included a 

cross-section of license types such as industrial radiography, broad scope medical and 

academic, nuclear medicine diagnostic and therapeutic, research and development, portable 

gauge, fixed gauge, nuclear pharmacy, and veterinary. A listing of the licensing casework 

reviewed, with comments, can be found in Appendix D. 

The review team found 12 of the 32 licensing actions either did not fully address health and 

safety concerns or indicated repeated examples of problems with respect to thoroughness, 

completeness, consistency, clarity, technical quality, and adherence to existing guidance in 

licensing actions. The review team concluded that actions taken in terminating licenses were 

appropriately documented, which included suitable material survey records and contained 

documentation of proper disposal or transfer of radioactive material. 

The Section has three fully qualified license reviewers and one partially qualified license 

reviewer. A majority of the licensing actions completed during the review period were done by 

one individual. The partially qualified license reviewer, who transitioned to licensing in January 

2013, became qualified to independently perform actions on industrial licenses in May 2013. 

Licenses are created and tracked using a local database. Once completed, all licensing actions 

are reviewed and signed by the Emergency Preparedness, Licensing & Administration Unit 

Manager. The Section uses the NRC’s NUREG-1556 series as its licensing guidance and also 

has a licensing procedure flow sheet. Contrary to the Section’s licensing procedure flow sheet, 

peer reviews of licensing actions were not being consistently performed during the review period 
Oregon Final IMPEP Report Page 7 

leading to inconsistency in licensing work products. The review team recommends that the 

Section follow its licensing procedure flow sheet and re-implement the peer review process to 

ensure consistency and accuracy for all licensing actions. 

The Section identified four licensees requiring financial assurance. Three licensees had 

appropriate financial assurance documents in place and one licensee was still in the process of 

obtaining the necessary documentation and providing it to the Section. The Section stated that 

they were in the final stages of collecting the documentation from the last licensee and expected 

to have the action completed within a month. The review team identified a fifth licensee that 

was licensed for material in quantities requiring financial assurance but did not have the 

appropriate financial assurance documents in place. This license is the Section’s own license 

and the Section stated that they did not want to lower the limits in case a situation occurred in 

the future that required them to take possession of material in excess of the limits requiring 

financial assurance. The review team determined that the Section did not possess quantities of 

material in excess of the limits which would require financial assurance at the time of the IMPEP 

review. The Section stated it would add a license condition to the license that stated that if they 

exceeded quantities of material in excess of those required for financial assurance, proper 

financial assurance documentation would need to be obtained. 

The Section’s license also allows for possession of radioactive material in quantities above 

those required for implementation of the ICs; however, the license did not contain the IC license 

condition nor does the Section implement the ICs since they do not possess material in excess 

of the quantities required for the implementation of the ICs. The Section stated that it wanted to 

keep the limits as stated on the license in case a situation arose that required them to take 

possession of radioactive material in quantities exceeding the IC threshold. The Section will 

add a license condition to its license stating that if it were to need to take possession of a 

quantity of radioactive material greater than the threshold for the IC’s then the Section would 

implement the ICs prior to taking possession of the material. 

The review team identified seven licenses where authorized users were added to the license 

without the proper documentation to verify the training, experience, and preceptor attestation. 

The review team found the Section was approving users, in some cases, with only a board 

certification, or only a preceptor attestation, or only a letter citing the doctor’s credentials and 

training. In addition, the Section approved users who submitted a preceptor attestation form 

that was not filled out correctly. The review team recommends that the State verify that all 

previously approved authorized users, authorized medical physicists, radiation safety officers on 

medical licenses, and authorized nuclear pharmacists have the proper board certification or 

training requirements and preceptor attestation, since the new requirements were initiated in 

2006. 

The review team reviewed six license renewals. Two of these renewals were composed of only 

two pages and a statement mirroring “no changes since the last inspection.” For these two 

renewals the reviewer deleted all of the previous tie-down conditions and placed the current 

renewal application as the only tie-down condition. The review team discussed with the Section 

whether or not the license in its current form was able to be inspected against and was 

enforceable based on commitments made in the licensee’s original application. The Section 

stated that they were unsure if the inspectors could inspect against and issue violations against 

a commitment made in the initial application even though the tie down condition referencing that 
Oregon Final IMPEP Report Page 8 

application had been removed and replaced with the two page submittal referencing no changes 

to the license since the last inspection. The Section stated it would evaluate its current renewal 

process to ensure that renewed licenses were both able to be inspected against and 

enforceable. 

The review team verified that the Section uses legally binding license conditions that meet the 

criteria for implementing the IC Orders, including fingerprinting, as appropriate. There are 

currently fifteen licenses required to meet these mandates. Files containing IC licenses are kept 

in a locked file drawer. The review team determined that these licenses and corresponding 

cover letters were marked as containing sensitive information as required, and that the Section 

is identifying and marking sensitive security-related information appropriately in accordance with 

their protocol. 

The Section has access to the National Source Tracking System (NSTS) and utilizes and 

updates the database, as necessary, when completing certain licensing actions. The Section 

did not have any licensees with outstanding NSTS reconciliations for 2012. 

The review team assessed the Section’s implementation of the pre-licensing guidance. The 

Section implemented NRC’s pre-licensing guidance issued on September 22, 2008, and 

transmitted to the Agreement States via FSME Letter RCPD-08-020, “Requesting 

Implementation of the Checklist to Provide a Basis for Confidence That Radioactive Material 

Will Be Used as Specified on a License and the Checklist for Risk-significant Radioactive 

Material,” however the guidance is being implemented incorrectly. If the new licensee is an IC 

licensee then, per Section policy, they automatically get a pre-licensing visit along with a full 

security inspection prior to issuance of the license. However if the new licensee is not an IC 

licensee and the Section determines that the applicant is registered as a business with the 

Oregon Secretary of State then the rest of the pre-licensing checklist is not utilized. The review 

team discussed with the Section that a business being registered with the Oregon Secretary of 

State did not make the applicant known to the Section and that the Section should utilize the 

pre-licensing checklists as appropriate to determine if a pre-licensing visit is warranted. The 

review team recommends that the State develop and implement a pre-licensing protocol based 

on the RCPD-08-020 letter issued on September 22, 2008 to enhance the basis for confidence 

that radioactive materials will be used as specified on a radioactive materials license. 

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

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

be found satisfactory, but needs improvement. 

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 Oregon in NMED against those 

contained in the Section’s files, and evaluated the casework for seven incidents which were 

reported to NMED and for seven incidents which were not reported to NMED. A list of the 

incident casework examined, with case-specific comments, can be found in Appendix E. The 

review team also evaluated the Section’s response to two allegations involving radioactive 

materials, including one allegation referred to the Section by the NRC during the review period. 
Oregon Final IMPEP Report Page 9 

The review team examined the Section’s implementation of its incident and allegation 

processes, including written protocols for handling allegations and incident response, file 

documentation, and notification of incidents to the NRC Headquarters Operations Center. 

When notification of an incident or an allegation is received, the Section’s Manager or designee 

determines the appropriate level of initial response. 

The Section has established standard operating protocols for responding to incidents and 

allegations. The protocols describe the actions to be taken upon the notification of an incident 

or allegation, proper documentation of incidents and allegations, and entering information into 

the Section's radioactive materials licensing (RML) database. The Section uses the RML 

database to keep track of incidents and allegations. The RML database is used by inspectors to 

identify incidents that require follow-up during the next routine inspection. Incidents that 

occurred during the review period were inspected and properly documented during the next 

routine inspection. 

The review team reviewed seven reportable radioactive material incidents in NMED for Oregon 

during the review period. The review team also reviewed seven radioactive materials incidents 

which the Section determined to be non-reportable. The incidents selected for review included 

the following categories: lost/stolen radioactive material, potential overexposure, medical event, 

equipment failure, and leaking source. The review team determined that the Section’s response 

to incidents was complete and comprehensive. Initial responses were prompt and 

well-coordinated, and the level of effort was commensurate with the health and safety 

significance of the incident. The Section dispatched inspectors for on-site investigations in three 

of the cases reviewed and took suitable enforcement and follow-up actions in all of the cases 

reviewed. 

While reviewing the casework for the seven events in NMED, the review team noted that, in six 

of the cases, the Section had closed the event report in NMED since the Section had concluded 

their follow-up/investigation but had not completed the event report in NMED by providing all of 

the information requested by the NMED contractor. Additionally, four of the seven cases in 

NMED were not reported in a timely manner in accordance with the reporting timelines 

established in the FSME Procedure SA-300 “Reporting Material Events.” The 2009 IMPEP 

review team recommended that the Section implement a process to ensure all required 

information is submitted to NMED and to also promote timely completion of NMED entries. This 

review team determined that the recommendation should stay open until the Section can 

effectively demonstrate that the established protocol is ensuring that all required information is 

submitted to NMED and that reportable events are completed in NMED in a timely manner. 

The review team selected an additional seven radioactive material incidents for evaluation from 

the Oregon RML database. The review team identified that two of the seven incidents should 

have been reported to the NRC Operations Center. One was a medical event that should have 

been reported within 24 hours after being notified by the licensee. The second incident was a 

lost tritium exit sign which should have been reported immediately after notification from the 

licensee. Additionally, there were two incidents associated with leaking radioactive sources that 

should have been reported to NMED within 30 days. The review team recommends that the 

State revise their protocol for reviewing incidents for reportability in accordance with FSME 
Oregon Final IMPEP Report Page 10 

Procedure SA-300 and to ensure timely reporting of events to the NRC Operations Center and 

to NMED. 

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

evaluated the completed casework for two allegations, including one that the NRC referred to 

the Section during the review period. The review team concluded that the Section took prompt 

and appropriate actions in response to concerns raised. One allegation was substantiated and 

the Section took appropriate enforcement action by issuing a notice of violation to the licensee. 

The other allegation was unsubstantiated. The review team noted that the Section documented 

the investigations of concerns and retained all necessary documentation to appropriately close 

the allegations. However, the review team identified that in both allegations the Section could 

not confirm that the concerned individuals were notified about the conclusion of the Section’s 

investigations. The review team informed the Section’s management of this issue and 

immediate action was taken to notify the concerned individuals and document the notification. 

The Section’s management committed to revising the protocols to ensure that concerned 

individuals are notified about the conclusions of the Section’s investigations of the concern(s). 

The review team determined that the Section adequately protected the identity of concerned 

individuals. 

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

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

Allegation Activities, be found satisfactory, but needs improvement. 

4.0 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) Low-Level Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. 

NRC’s Agreement with Oregon does not relinquish regulatory authority for a sealed source and 

device evaluation program, low level radioactive waste disposal program, or a uranium recovery 

program; therefore, only the first non-common performance indicator applied to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Oregon became an Agreement State on July 1, 1965. The current effective statutory authority 

is contained in Volume 11 Chapter 453 Hazardous Substances, Radiation Sources, of the 

Oregon Revised Statutes. The Section is designated as the State’s radiation control agency. 

The review team noted that no legislation affecting the radiation control program was passed 

during the review period. 

4.1.2 Program Elements Required for Compatibility 

The Oregon regulations governing radiation protection requirements are located in 

Chapter 333, Divisions 100-124 of the Oregon Administrative Rules and apply to all persons 

who receive, possess, use, transfer, own, or acquire any source of radiation. Oregon requires 

a license for the receipt, possession, use, ownership, or transfer of all radioactive material, 
Oregon Final IMPEP Report Page 11 

including byproduct, source, certain quantities of special nuclear material, 

accelerator-produced radionuclides, and naturally-occurring materials, such as radium. 

Oregon also requires registration of all equipment designed to produce x-rays or other ionizing 

radiation. 

The review team examined the State’s administrative rulemaking process and found that the 

process takes six months to a year from the development stage to the final approval. The final 

rule is submitted to the Secretary of State and then is published as a final rule. The final rule 

becomes effective after publication. The public, NRC, other agencies, and potentially impacted 

licensees and registrants are offered an opportunity to comment during the process. Comments 

are considered and incorporated, as appropriate, before the regulations are finalized and 

approved. 

The review team noted that the State’s rules and regulations are not subject to “sunset” laws. 

The State may adopt the regulations of another agency by reference and also 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 Oregon’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. 

During the review period, Oregon submitted seven final regulation amendments for a 

compatibility review. Current NRC policy requires that Agreement States adopt certain 

equivalent regulations or legally-binding requirements no later than three years after they 

become effective. Five of the amendments were overdue for State adoption at the time of 

submission. The NRC’s compatibility review resulted in six comments, which will need to be 

addressed by the State in upcoming rulemaking activities. The following five amendments were 

submitted overdue during this review period: 

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

15005) that was due for Agreement State adoption on March 27, 2009. [OR final rule 

submittal April 15, 2010] 

• “Medical Use of Byproduct Material - Minor Corrections and Clarifications,” 10 CFR Parts 

32 and 35 (72 FR 45147) that was due for Agreement State adoption on October 29, 

2010. [OR final rule submittal December 14, 2011] 

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

32, 33, 35, 61, 150 (72 FR 55864) that was due for Agreement State adoption on 

November 30, 2010. [OR final rule submittal December 14, 2011] 

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

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

adoption on January 3, 2011. [OR final rule submittal December 14, 2011] 

• “Medical Use of Byproduct Material – Authorized User Clarification,” 10 CFR Part 35 (74 
Oregon Final IMPEP Report Page 12 

FR 33901) that was due for Agreement State adoption on September 28, 2012. [OR final 

rule submittal April 29, 2013] 

At the time of this review, there were no amendments overdue for adoption. The review team 

recommends that the State develop and implement a protocol to ensure that regulations 

required for adoption are adopted within 3 years as required in the Policy Statement on 

Adequacy and Compatibility of Agreement State Programs. 

A complete list of upcoming regulation amendments that will need to be addressed can be found 

on the NRC website at the following address: http://nrc-stp.ornl.gov/rss_regamendents.html. 

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

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

satisfactory. 

4.2 Low-Level Radioactive Waste Disposal Program

In 1981, the NRC amended its Policy Statement, "Criteria for Guidance of States and NRC in 

Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through 

Agreement," to allow a State to seek an amendment for the regulation of LLRW as a separate 

category. Although the Oregon Agreement State Program has LLRW disposal authority, NRC 

has not required States to have a program for licensing a LLRW disposal facility until such time 

as the State has been designated as a host State for a LLRW disposal facility. When an 

Agreement State has been notified or becomes aware of the need to regulate a LLRW disposal 

facility, they are expected to put in place a regulatory program which will meet the criteria for an 

adequate and compatible LLRW disposal program. There are no plans for a LLRW disposal 

facility in Oregon. Accordingly, the review team did not review this indicator. 

5.0 SUMMARY 

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

out of six performance indicators reviewed and satisfactory, but needs improvement, for the 

indicators Technical Quality of Licensing Actions and Technical Quality of Incidents and 

Allegation Activities. The review team made five recommendations regarding program 

performance by the State and determined that one recommendation from the 2009 IMPEP 

review should be kept open. 

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

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

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 four years. 

 
Oregon Final IMPEP Report Page 13 

Below are the review team’s recommendations, as mentioned in the report, for evaluation and 

implementation by the State: 

RECOMMENDATIONS 

1. The review team recommends that the Section follow its licensing procedure flow sheet 

and re-implement the peer review process to ensure consistency and accuracy for all 

licensing actions. (Section 3.4) 

2. The review team recommends that the State verify that all previously approved 

authorized users, authorized medical physicists, radiation safety officers on medical 

licenses, and authorized nuclear pharmacists have the proper board certification or 

training requirements and preceptor attestation, since the new requirements were 

initiated in 2006. (Section 3.4) 

3. The review team recommends that the State develop and implement a pre-licensing 

protocol based on the RCPD-08-020 letter issued on September 22, 2008 to enhance 

the basis for confidence that radioactive materials will be used as specified on a 

radioactive materials license. (Section 3.4) 

4. The review team recommends that the Section implement a process to ensure all 

required information is submitted to NMED and to also promote timely completion of 

NMED entries. (Section 3.5 remains open from 2009 IMPEP) 

5. The review team recommends that the State revise its protocol for reviewing incidents 

for reportability in accordance with FSME Procedure SA-300 and to ensure timely 

reporting of events to the NRC Operations Center and to NMED. (Section 3.5) 

6. The review team recommends that the State develop and implement a protocol to 

ensure that regulations required for adoption are adopted within 3 years as required in 

the Policy Statement on Adequacy and Compatibility of Agreement State Programs. 

(Section 4.1) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Oregon Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source and Device Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Monica Ford, Region I Team Leader 

 Technical Staffing and Training 

 Status of Materials Inspection Program 

 Compatibility Requirements 

Randy Erickson, Region IV Technical Quality of Inspections 

 Inspector Accompaniments 

Brian Goretzki, Arizona Technical Quality of Licensing Actions 

Binesh Tharakan, Region IV Technical Quality of Incidents and Allegation 

Activities 
APPENDIX B 

OREGON ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML13206A255 
 

 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Oregon Health & Science University License No.: ORE-90013 

Inspection Type: Special/Routine/Unannounced Priority: 2 

Inspection Date: 11/15/10 Inspector: JS 

File No.: 2 

Licensee: Oregon Washington Laboratories License No.: ORE-91149 

Inspection Type: Special/Routine/Unannounced Priority: 1 

Inspection Date: 2/12/13 Inspector: DL 

File No.: 3 

Licensee: Providence Health & Services-Oregon License No.: ORE-90946 

Inspection Type: Special/Unannounced Priority: 2 

Inspection Date: 2/25/10 Inspector: JS 

File No.: 4 

Licensee: Acuren Inspection, Inc. License No.: ORE-90621 

Inspection Type: Special/Routine/Unannounced Priority: 1 

Inspection Date: 9/26/12 Inspector: RB 

File No.: 5 

Licensee: Peace Health Sacred Heart Medical Center License No.: ORE-91054 

Inspection Type: Special/Unannounced Priority: 2 

Inspection Date: 3/28/12 Inspector: KS 

File No.: 6 

Licensee: Professional Service Industries, Inc. License No.: ORE-99056 

Inspection Type: Field/Special/Unannounced Priority: 1 

Inspection Date: 2/24/10 Inspector: KS 

File No.: 7 

Licensee: Oregon Health & Science University License No.: ORE-90731 

Inspection Type: Special/Routine/Unannounced Priority: 3 

Inspection Date: 4/13/12 Inspector: DL 

File No.: 8 

Licensee: TDY Industries, LLC License No.: ORE-90728 

Inspection Type: Special/Routine/Unannounced Priority: 1 

Inspection Date: 6/9/11 Inspector: DL 

 
Oregon Final IMPEP Report Page C. 2 

Inspection Casework Reviews 

File No.: 9 

Licensee: International Inspection, Inc. License No.: ORE-90651 

Inspection Type: Special/Routine/Unannounced Priority: 1 

Inspection Date: 7/30/13 Inspector: KS 

File No.: 10 

Licensee: Providence Health & Services, Oregon License No.: ORE-90946 

Inspection Type: Special/Routine/Unannounced Priority: 2 

Inspection Date: 3/20/12 Inspectors: KS 

File No.: 11 

Licensee: Legacy Good Samaritan License No.: ORE-91155 

Inspection Type: Pre-Licensing/Special/Unannounced Priority: 2 

Inspection Date: 10/18/12 Inspector: RB 

File No.: 12 

Licensee: Bay Area Hospital License No.: ORE-90358 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 9/28/10 Inspector: KS 

File No.: 13 

Licensee: Community Cancer Center License No.: ORE-90422 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 10/16/12 Inspector: KS 

File No.: 14 

Licensee: Legacy Good Samaritan Med. Center Radiation Oncology License No.: ORE-91155 

Inspection Type: Initial/Special/Announced Priority: 2 

Inspection Date: 3/6/12 Inspector: DL 

File No.: 15 

Licensee: OHA Public Health Division License No.: ORE-90269 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 12/19/12 Inspector: RB 

File No.: 16 

Licensee: Oncology Associates of Oregon License No.: ORE-90862 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 3/20/13 Inspector: KS 

File No.: 17 

Licensee: Cardinal Health License No.: ORE-90509 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 11/21/12 Inspector: RB 
Oregon Final IMPEP Report Page C. 3 

Inspection Casework Reviews 

File No.: 18 

Licensee: ISOSCAN License No.: ORE-91039 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 11/9/12 Inspector: DL 

File No.: 19 

Licensee: SHS Mobile PET/CT License No.: ORE-91148 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 11/27/12 Inspector: KS 

File No.: 20 

Licensee: Compass Oncology License No.: ORE-91121 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 12/17/09 Inspector: JS 

File No.: 21 

Licensee: Mistras Services License No.: ORE-96130 

Inspection Type: Reciprocity/Unannounced Priority: 3 

Inspection Date: 9/10/12 Inspectors: KS 

File No.: 22 

Licensee: Reed College License No.: ORE-90010 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 10/18/12 Inspectors: RB 

File No.: 23 

Licensee: Triad Isotopes, Inc. License No.: ORE-90702 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 10/12/12 Inspector: RB 

File No.: 24 

Licensee: PCC Structurals, Inc. License No.: ORE-90354 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 3/23/10 Inspector: DL 

File No.: 25 

Licensee: H & H X-Ray License No.: ORE-96112 

Inspection Type: Reciprocity/Unannounced Priority: 1 

Inspection Date: 7/22/10 Inspectors: DL 

File No.: 26 

Licensee: Northwest Inspection, Inc. License No.: ORE-96131 

Inspection Type: Reciprocity/Unannounced Priority: 1 

Inspection Date: 10/25/12 Inspector: RB 
Oregon Final IMPEP Report Page C. 4 

Inspection Casework Reviews 

File No.: 27 

Licensee: Halliburton Energy Services License No.: ORE-96058 

Inspection Type: Reciprocity/Unannounced Priority: 2 

Inspection Date: 6/6/13 Inspector: RB 

INSPECTOR ACCOMPANIMENTS 

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

Licensee: International Inspection, Inc. License No.: ORE-90651 

Inspection Type: Special/Routine/Unannounced Priority: 1 

Inspection Date: 7/30/13 Inspector: KS 

Licensee: Legacy Good Samaritan Medical Center License No.: ORE-91155 

Inspection Type: Special/Initial/Unannounced Priority: 2 

Inspection Date: 7/31/13 Inspector: DL 
 

APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Cardinal Health 414 License No.: ORE-91142 

Type of Action: Amendment Amendment No.: 07 

Date Issued: 06/21/2013 License Reviewer: SM 

File No.: 2 

Licensee: Eugene Sand and Gravel License No.: ORE-90643 

Type of Action: Amendment Amendment No.: 11 

Dates Issued: 03/22/2013 License Reviewer: ED 

File No.: 3 

Licensee: PETNET Solutions, Inc. License No.: ORE-90926 

Type of Action: Amendment Amendment No.: 26 

Dates Issued: 10/04/2012 License Reviewer: SM 

Comment: An authorized nuclear pharmacist was added to the license without proper 

documentation regarding training, experience, and preceptor attestation. 

File No.: 4 

Licensee: DOW AgroSciences, LLC License No.: ORE-90855 

Type of Action: Renewal Amendment No.: 12 

Date Issued: 02/27/2013 License Reviewer: SM 

Comment: A renewal application was submitted on 1/30/2013 and items 5-12 consisted of the 

phrase “No changes since Agency inspection conducted May 21, 2009 or last 

amendment (number 11).” All of the previous tie-down conditions are removed and 

the new renewal date is placed into the tie-down condition. 

File No.: 5 

Licensee: St. Anthony Hospital License No.: ORE-90353 

Type of Action: Amendment Amendment No.: 36 

Date Issued: 03/14/2013 License Reviewer: SM 

File No.: 6 

Licensee: Legacy Health Radiation Safety/Imaging License No.: ORE-90293 

Type of Action: Amendment Amendment No.: 86/89 

Date Issued: 11/9/2012 License Reviewer: SM 

Comment: An authorized user was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 
Oregon Final IMPEP Report Page D.2 

License Casework Reviews 

File No.: 7 

Licensee: Legacy Health System Radiation Safety/Imaging License No.: ORE-90181 

Type of Action: Amendment Amendment No.: 71 

Date Issued: 06/10/2013 License Reviewer: ED/SM 

Comment: An authorized user was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

File No.: 8 

Licensee: Klamath Pacific Company License No.: ORE-90985 

Type of Action: Amendment Amendment No.: 11 

Date Issued: 03/29/2013 License Reviewer: SM 

File No.: 9 

Licensee: Salem Hospital License No.: ORE-91006 

Type of Action: Amendment Amendment No.: 18 

Date Issued: 03/29/2013 License Reviewer: SM/ED 

Comment: Two authorized medical physicists were added to the license without proper 

documentation regarding training, experience, and preceptor attestation. 

File No.: 10 

Licensee: Oregon Advanced Imaging License No.: ORE-91001 

Type of Action: Amendment Amendment No.: 15 

Date Issued: 02/22/2013 License Reviewer: SM/ED 

File No.: 11 

Licensee: NMCSI (Hillsboro Cardiology) License No.: ORE-90996 

Types of Action: /Renewal Amendment No.: 10 

Dates Issued: 08/28/2012 License Reviewer: SM 

Comment: The licensee submitted a renewal application on 08/14/2012, which included an 

addition of an authorized user. The authorized user was added to the license 

without proper documentation regarding training, experience, and preceptor 

attestation. 

File No.: 12 

Licensee: West Valley Hospital License No.: ORE-91087 

Types of Action: Amendment Amendment No.: 04 

Dates Issued: 06/13/2013 License Reviewer: ED 

File No.: 13 

Licensee: Cascade Medical Imaging, LLC License No.: ORE-91131 

Type of Action: Amendment Amendment No.: 07 

Date Issued: 11/27/12 License Reviewer: SM 
Oregon Final IMPEP Report Page D.3 

License Casework Reviews 

File No.: 14 

Licensee: Oncology Associated of Oregon License No.: ORE-90789 

Type of Action: Amendment Amendment No.: 23 

Date Issued: 07/09/2013 License Reviewer: SM 

File No.: 15 

Licensee: Asante Rogue Regional Medical Center Cardiac Studies License No.: ORE-90944 

Type of Action: Amendment Amendment No.: 09 

Date Issued: 11/11/2009 License Reviewer: SM 

Comment: An authorized user was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

File No.: 16 

Licensee: Four Rivers Veterinary Clinic License No.: ORE-90972 

Type of Action: Renewal Amendment No.: 02 

Date Issued: 06/21/2011 License Reviewer: SM 

File No.: 17 

Licensee: Providence St. Vincent Heart Clinics-Cardiology License No.: ORE-90793 

Type of Action: Renewal Amendment No.: 206 

Date Issued: 10/18/2011 License Reviewer: SM 

File No.: 18 

Licensee: NMCSI (Cascade Cardiology) License No.: ORE-91076 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 02/02/2012 License Reviewer: SM 

Comment: An authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 19 

Licensee: Acuren Inspection, Inc. License No.: ORE-90621 

Type of Action: Amendment Amendment No.: 85C 

Date Issued: 12/27/2012 License Reviewer: SM 

File No.: 20 

Licensee: Eastern Oregon University License No.: ORE-90142 

Type of Action: Termination Amendment No.: 31 

Date Issued: 06/28/2013 License Reviewer: SM 

File No.: 21 

Licensee: Calbag Metals Company License No.: ORE-90406 

Type of Action: Termination Amendment No.: 11 

Date Issued: 04/21/2011 License Reviewer: SM 
Oregon Final IMPEP Report Page D.4 

License Casework Reviews 

File No.: 22 

Licensee: Boise White Paper LLC License No.: ORE-90100 

Types of Action: Termination Amendment No.: 56 

Dates Issued: 03/22/2013 License Reviewer: SM 

File No.: 23 

Licensee: Curry Medical Center License No.: ORE-91143 

Types of Action: New Amendment No.: 01 

Dates Issued: 12/20/2011 License Reviewer: SM/ED 

File No.: 24 

Licensee: PCC Structurals, Inc. License No.: ORE-90354 

Type of Action: Amendment Amendment No.: 54 

Date Issued: 07/22/2013 License Reviewer: SM/ED 

File No.: 25 

Licensee: Oregon Washington Laboratories License No.: ORE-91149 

Type of Action: New Amendment No.: 01 

Date Issued: 0702/2011 License Reviewer: SM 

File No.: 26 

Licensee: Silverton Hospital License No.: ORE-90886 

Type of Action: Amendment Amendment No.: 22 

Date Issued: 02/17/2012 License Reviewer: SM/ED 

Comment: An authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 27 

Licensee: Nuclear Medicine Consulting Services, Inc. License No.: ORE-90961 

Type of Action: Amendment Amendment No.: 12 

Date Issued: 10/25/2012 License Reviewer: SM/ED 

Comment: An authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 
Oregon Final IMPEP Report Page D.5 

License Casework Reviews 

File No.: 28 

Licensee: Tuality/OHSU Cancer Center License No.: ORE-91048 

Types of Action: Renewal Amendment No.: 10/11 

Dates Issued: 02/11/2011 License Reviewer: SM 

Comments: 

a) A license renewal was submitted on 01/04/2011. The application consisted of a 

one page renewal with the statement “No changes since last inspection (no items 

of non-compliance) 3/16/2010” for items 5-12. All previous tie-down conditions 

were taken off and the new application was placed as the only tie-down 

condition. 

b) An authorized user was added on the previous amendment without sufficient 

information provided by the licensee. 

File No.: 29 

Licensee: OHA Public Health Division License No.: ORE-90269 

Types of Action: Renewal Amendment No.: 30 

Dates Issued: 11/27/2012 License Reviewer: SM 

Comment: The license currently allows for quantities above those requiring implementation of 

the ICs and those requiring financial assurance but does not contain a license 

condition requiring implementation of the ICs or contain any financial assurance 

documentation in the file. 

File No.: 30 

Licensee: Sherman County Soil & Water Conservation District License No.: ORE-91161 

Type of Action: New Amendment No.: 1 

Dates Issued: 07/11/2013 License Reviewer: ED 

Comment: The licensee submitted a new application for a portable gauge license. A prelicensing checklist was not utilized and a pre-licensing visit was not performed. 

File No.: 31 

Licensee: Carlson Testing, Inc. License No.: ORE-90924 

Type of Action: Amendment Amendment No.: 17 

Dates Issued: 06/06/2013 License Reviewer: DAL
 

APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Jeld-Wen Wood Fiber of Oregon License No.: 90307 

Date of Incident: 03/15/10 NMED No.: 100458 

Investigation Date: 03/15/10 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone/E-mail 

Comment: The 24-hour notification to the NRC Headquarters Operations Center was late. It 

was not made until 09/10/10; six months after the Section became aware of the 

incident on 03/15/10. 

File No.: 2 

Licensee: Hillsboro Landfill License No.: 91120 

Date of Incident: 08/15/11 NMED No.: 110408 

Investigation Date: 09/01/11 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Site 

File No.: 3 

Licensee: Test America Analytical Testing License No.: 90559 

Date of Incident: 06/01/12 NMED No.: 120345 

Investigation Date: 06/14/12 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Site 

Comment: The Section closed the incident on 01/10/13, but the NMED record was not 

completed until 08/14/13 when it was identified by the review team. 

File No.: 4 

Licensee: Oregon Health and Science University License No.: 90013 

Date of Incident: 08/13/12 NMED No.: 120486 

Investigation Date: 08/20/12 Type of Incident: Medical Event 

 Type of Investigation: Email 

Comments: 

a) The 24-hour notification to the NRC Headquarters Operations Center was late. It 

was not made until 8/20/12; six days after the licensee became aware of the 

incident. 

b) The Section closed the incident 09/19/12, but the NMED record was not 

completed until 08/14/13 when it was identified by the review team.
Oregon Final IMPEP Report Page E.2 

Incident Casework Reviews 

 

File No.: 5 

Licensee: Evonik Corp License No.: N/A 

Date of Incident: 02/14/13 NMED No.: 130106 

Investigation Date: 02/14/13 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Telephone/Email 

Comment: The Section closed the incident on 06/06/13, but NMED record was not completed 

until 08/14/13 when it was identified by the review team. 

File No.: 6 

Licensee: Oregon State Fire Marshal License No.: 93209 

Date of Incident: 09/01/10 NMED No.: 130326 

Investigation Date: 02/17/11 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Telephone/Email 

Comments: 

a) The 24-hour notification to the NRC Headquarters Operations Center was not 

made until it was identified by the Section during a self-audit on 07/19/13. 

b) The Section closed the incident 09/02/11, but NMED record was not completed 

until 08/15/13 when it was identified by the review team. 

File No.: 7 

Licensee: Good Samaritan Regional Medical Center License No.: 90202 

Date of Incident: 11/01/10 NMED No.: 130327 

Investigation Date: 01/19/11 Type of Incident: Potential Overexposure 

 Type of Investigation: Telephone/Email 

Comments: 

a) The 24-hour notification to the NRC Headquarters Operations Center was not 

made until it was identified by the Section during a self-audit on 07/19/13. 

b) The Section closed the incident 01/10/12, but NMED record was not completed 

until 08/15/13 when it was identified by the review team. 

File No.: 8 

Licensee: Legacy Meridian Park Medical Center License No.: 90293 

Date of Incident: 11/03/11 NMED No.: N/A 

Investigation Date: 11/09/11 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Email 

Comment: The Section did not identify this incident as a medical event and did not report it to 

the NRC Headquarters Operations Center the next calendar day. The review team 

identified this incident qualified as a medical event and informed the Section to 

review the incident and make the appropriate notifications. The Section reported 

this to NRC’s Headquarters Operations Center on August 15, 2013. 
Oregon Final IMPEP Report Page E.3 

Incident Casework Reviews 

 

 

File No.: 9 

Licensee: Kaiser Permanente Interstate License No.: 90126 

Date of Incident: 03/10/10 NMED No.: N/A 

Investigation Date: 03/11/10 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Email 

File No.: 10 

Licensee: Oregon Health and Science University License No.: 90731 

Date of Incident: 10/28/09 NMED No.: N/A 

Investigation Date: 12/23/09 Type of Incident: Leaking Source 

 Type of Investigation: Telephone/Email 

Comment: The 30-day report to NMED was not made until 08/15/13 when it was identified by 

the review team. 

File No.: 11 

Licensee: Oregon State University License No.: 90005 

Date of Incident: 03/15/10 NMED No.: N/A 

Investigation Date: 03/15/10 Type of Incident: Leaking Source 

 Type of Investigation: Telephone/Email 

Comment: The 30-day report to NMED was not made until 08/15/13 when it was identified by 

the review team. 

File No.: 12 

Licensee: Carestream Health Inc. License No.: 90879 

Date of Incident: 02/06/13 NMED No.: N/A 

Investigation Date: 02/20/13 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Telephone/Email 

Comment: The immediate telephone report to the NRC Headquarters Operations Center was 

not made for a lost tritium exit sign. The report was made on 08/15/13 when it was 

identified as being reportable by the review team. 

File No.: 13 

Licensee: Southern Oregon Historical Society License No.: N/A 

Date of Incident: 07/12/11 NMED No.: N/A 

Investigation Date: 07/12/11 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Telephone/E-mail 

File No.: 14 

Licensee: Columbia Inspections License No.: 93138 

Date of Incident: 07/08/10 NMED No.: 100375 

Investigation Date: 07/08/10 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Site
 

 

ATTACHMENT 

October 14, 2013 letter from David M. Howe 

Oregon’s Response to the Draft Report 

ADAMS Accession No.: ML13291A040