UNITED STATES

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

February 4, 2015 

Steven Harrison, Director 

Office of Radiological Health 

Virginia Department of Health 

James Madison Building 

109 Governor Street, Room 736 

Richmond, VA 23219 

Dear Mr. Harrison: 

On January 15, 2015, the Management Review Board (MRB) met to consider the proposed final 

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

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

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

Section 5.0, page 9, of the enclosed final report contains a summary of the IMPEP team’s 

findings. Based on the results of the current IMPEP review, the next full review of the Virginia 

Agreement State Program will take place in approximately 5 years, with a periodic meeting 

tentatively scheduled for May 2017. The next IMPEP review was extended by 1 year because 

of Virginia’s sustained high level of performance. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Agreement State program. I look 

forward to our agencies continuing to work cooperatively in the future. 

 Sincerely, 

 /RA/ 

 Michael F. Weber 

 Deputy Executive Director for 

 Materials, Waste, Research, State, Tribal and 

 Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Virginia Final IMPEP Report 

cc: See next page
cc: 

Gonzalo Perez, CA 

Organization of Agreement States 

 Liaison to the MRB 

Mike Welling, Assistant Director 

Radioactive Materials 

Brett Burdick, 

Acting State Coordinator 

Virginia Department of 

 Emergency Management 
Steven Harrison, Director 

Office of Radiological Health 

Virginia Department of Health 

James Madison Building 

109 Governor Street, Room 736 

Richmond, VA 23219 

Dear Mr. Harrison: 

On January 15, 2015, the Management Review Board (MRB) met to consider the proposed final 

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

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

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

Section 5.0, page 9, of the enclosed final report contains a summary of the IMPEP team’s 

findings. Based on the results of the current IMPEP review, the next full review of the Virginia 

Agreement State Program will take place in approximately 5 years, with a periodic meeting 

tentatively scheduled for May 2017. The next IMPEP review was extended by 1 year because 

of Virginia’s sustained high level of performance. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Agreement State program. I look 

forward to our agencies continuing to work cooperatively in the future. 

 Sincerely, 

 /RA/ 

 Michael F. Weber 

 Deputy Executive Director for 

 Materials, Waste, Research, State, Tribal and 

 Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Virginia Final IMPEP Report 

cc: see next page 

Distribution: (SP05) see next page

ML15026A028 Package 

OFC MSTR/ASPB MSTR/ASPB RIV NMSS/MSTR Tech Ed NMSS EDO 

NAME LDimmick / 

ADW 

DWhite RErickson 

via email 

LDudes 

(PHenderson for)

CPoland CHaney MWeber 

DATE 1/21/15 1/21/15 1/22/15 01/27/15 1/28/15 1/29/15 02/04/15 

OFFICIAL RECORD COPY 
Letter to S. Harrison from M. Weber dated: February 4, 2015 

SUBJECT: VIRGINIA FY2015 FINAL IMPEP REPORT 

DISTRIBUTION: (SP05) 

RidsEdoMailCenter 

JFoster, OEDO 

RidsOgcMailCenter 

JOlmstead, OGC 

RidsRgn3MailCenter 

DRoberts, RIII 

RidsRgn1MailCenter 

DCollins, RI 

JDwyer, RI 

RidsSecyCorrespondenceMailCenter Chairman Burns 

KMcConnell, NMSS Commissioner Svinicki 

PHenderson, MSTR Commissioner Ostendorff 

DJanda, RI/RSAO Commissioner Baran 

GWarren, RIII SECY 

CGraham, OH 

MAbogunde, MSTR 

JO’Hara, MSTR 

OAS Board 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE VIRGINIA AGREEMENT STATE PROGRAM 

NOVEMBER 3–7, 2014 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

the period of November 3–7, 2014, by a review team composed of technical staff members 

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

Based on the results of this review, the review team recommended that Virginia’s performance 

be found satisfactory for five of six indicators reviewed, and satisfactory, but needs improvement 

for the indicator Status of the Materials Inspection Program. Early in the review period, the 

Program experienced a backlog in inspections due, in part, to having a shortage of qualified 

staff to complete inspections within the required timeframe. The Program took corrective action 

to eliminate the backlog of overdue inspections. The Management Review Board (MRB) 

determined the Status of the Materials Inspection Program should be found satisfactory. The 

MRB found the Commonwealth addressed the root cause of the overdue inspections and took 

effective corrective action. 

The review team found, and the MRB agreed, that the recommendation from the 2010 IMPEP 

review regarding the use of qualification journals and the tracking of training and qualification of 

the staff was addressed by the Program and can be closed. 

The review team recommended, and the MRB agreed, that the Virginia Agreement State 

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

NRC's program. The review team recommended the periodic meeting be held in two years and 

the next IMPEP review take place in approximately four years. However, the MRB determined 

the next IMPEP should be in five years since all performance indicators were found satisfactory 

(on two consecutive IMPEP reviews) following MRB deliberations.
Virginia Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of November 3-7, 2014, by a review team composed of 

technical staff members from the NRC and the State of Ohio. 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 

November 5, 2010, to November 7, 2014, were discussed with Virginia managers on the last 

day of the review. 

A draft of this report was issued to Virginia on November 24, 2014, for factual comment. 

Virginia responded to the findings and conclusions of the review by letter dated 

November 25, 2014. A copy of the Commonwealth’s response is included as an attachment to 

this report. The MRB met on January 15, 2015, to consider the proposed final report. The MRB 

found the Virginia Agreement State Program adequate to protect public health and safety, and 

compatible with the NRC’s program. 

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

(the Program), in the Office of Radiological Health (the Office). Organization charts for the 

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

At the time of the review, the Virginia Agreement State Program regulated 401 specific licenses 

authorizing byproduct, source, and certain special nuclear materials. The review focused on the 

radioactive materials program as it is carried out under the Section 274b. (of the Atomic Energy 

Act of 1954, as amended) Agreement between the NRC and the Commonwealth of Virginia. 

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

non-common performance indicators was sent to the Program on July 24, 2014. The Program 

provided its response to the questionnaire on October 10, 2014. 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 ML14289A284. 

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

the Program’s response to the questionnaire, (2) review of applicable Virginia statutes and 

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

review of selected regulatory actions, (5) field accompaniments of five inspectors, and 

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

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

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

performance. 

Section 2.0 of this report covers the Program’s actions in response to the open recommendation 

from the previous review. 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. 
Virginia Final IMPEP Report Page 2 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on November 5, 2010, the review team 

made one recommendation regarding the Virginia Agreement State Program’s performance. 

The status of the recommendation is as follows: 

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

licensing and inspection qualification journals for each staff member. (Section 2.1)” 

Status: Qualification journals are provided as a reference document to each technical staff 

member undergoing the qualification process. Licensing and inspection qualification training, 

including on the job training, and prior experience are tracked on a spreadsheet, which is 

maintained by the Program Director. All technical staff has “read only” access to the 

spreadsheet to ensure the information is accurate and the staff members are aware of their 

qualification status. The review team recommended, and the MRB agreed, that this 

recommendation be closed. 

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 Program’s staffing level and staff 

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

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

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

considered any workload backlogs. 

The Virginia Agreement State Program is composed of the Program Director, five Radiation 

Safety Specialists, and two Administrative Assistants. Three Radiation Safety Specialists are 

located in the main office in Richmond, and the other two telework from Bristol and Yorktown. 

Having two of the Radiation Safety Specialists work remotely allows program coverage of the 

entire Commonwealth on short notice, if required. Each Radiation Safety Specialist has at least 

a bachelor’s degree in a physical or life science and has several years of professional 

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

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

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

by the Program, the review team estimated that the Program expends approximately 6.0 

full-time equivalents (FTE), including Program management, to administer the Agreement State 

program. 

During the review period, no technical staff or managers left the Program. One Radiation Safety 

Specialist joined the Program in March 2012 as a contractor and became a full-time employee 

in August 2013. This employee is currently undergoing qualification training. Another Radiation 
Virginia Final IMPEP Report Page 3 

Safety Specialist, who was hired during the previous review period, was undergoing qualification 

training during 2011 and 2012. During this time, the Program experienced a backlog in 

inspections due, in part, to having a shortage of qualified staff to complete inspections within the 

required timeframe. This backlog is discussed in more detail in Section 3.2, Status of Materials 

Inspection Program. The backlog was corrected after one of the two new Radiation Safety 

Specialists was fully qualified. 

At the time of the review, the only vacancy in the Program was for an Administrative Assistant 

position. Since 2010, this position has been filled three times and has now been vacant since 

September 2014. The Office is proposing to senior management that the position be converted 

from a contractor to a full-time employee. The review team noted that the Administrative 

Assistant’s duties have been temporarily absorbed by the Program Manager and various 

technical staff members. The review team concluded that the vacancy does not have a major 

impact on the day-to-day operations of the Agreement State program. 

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

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

NRC’s Inspection Manual Chapter (IMC) 1248, “Formal Qualifications Program for Federal and 

State Material and Environmental Management Programs.” The Program uses on-the-job 

training, such as inspector accompaniments, to supplement formal coursework. Staff members 

are typically assigned increasingly complex duties as they progress through the qualification 

process. Staff members are authorized to perform regulatory duties independently after 

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

State, the Commonwealth submitted and committed to using qualification journals for each of its 

staff members. Currently the qualification journals are used as a reference document. The 

Program Director tracks each staff member’s training and licensing and inspection activities 

electronically using a spreadsheet. The Program Director maintains a password protected 

electronic spreadsheet for tracking the member’s licensing and inspection qualification 

approvals. Members have “read only” access to view their approvals. 

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

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

and training is adequate to carry out its regulatory duties. 

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

that Virginia’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 issuance of inspection findings to 

licensees, and performance of reciprocity inspections. The review team’s evaluation was based 

on the Program's questionnaire response relative to this indicator, data gathered from the 

Program’s database, examination of completed inspection casework, and interviews with 

Program managers and staff members. 
Virginia Final IMPEP Report Page 4 

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

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

IMC 2800, “Materials Inspection Program.” 

The Program conducted a total of 291 inspections of high priority (Priority 1, 2, and 3) licensees 

and 65 initial inspections during the review period. Of the 291 high priority inspections, the 

review team determined that 37 inspections were completed overdue by more than 25 percent 

of the inspection frequency prescribed in IMC 2800, and that one high priority inspection was 

overdue at the time of the review. Of the 65 initial inspections, the review team determined that 

22 inspections were completed more than 12 months after license issuance and that no initial 

inspections were overdue at the time of the review. Overall, the review team calculated that the 

Program performed 16.8 percent of its inspections overdue during the review period. 

The Program had lost two inspection personnel before the previous review. In order to fill these 

positions, one individual had been hired before the previous review and one was hired soon 

after the review. Because these two individuals took time to become fully trained, the Program 

was unable to perform all inspections before they became overdue. Once the Program fell 

behind, it acted to minimize the number of overdue inspections. Program management 

prioritized inspections, first performing inspections that would soon become overdue, then 

routine inspections that were already overdue, then initial inspections that were already 

overdue. The Program prioritized routine inspections over initial inspections because most of 

the routine inspections were of high-priority licensees whereas most of the initial inspections 

were of low-priority licensees. At the time of the review, the Program had reduced the number 

of overdue inspections to one routine inspection. 

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

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

inspection. The review team determined that the majority of inspection reports, significantly 

more than 90 percent, were issued within the 30-day goal. 

During the review period, the Program performed more than the 20 percent requirement of 

candidate licensees operating under reciprocity each year as described in IMC 1220 

“Processing of NRC Form 241 and Inspection of Agreement State Licensees Operating Under 

10 CFR 150.20”. The percentages for each calendar year ranged from 21 to 54 percent. 

Based on the IMPEP evaluation criteria, the review team recommended that Virginia's 

performance with respect to the indicator, Status of Materials Inspection Program, be found 

satisfactory but needs improvement. The MRB acknowledged the IMPEP team’s findings, yet 

concluded that the Commonwealth’s performance with respect to the indicator, Status of 

Materials Inspection Program, be found satisfactory. The MRB found that the inspection 

backlog presented by the IMPEP team occurred early in the review period. The Commonwealth 

addressed the root cause of the overdue inspections and took effective corrective action to 

address the weakness. The Commonwealth appropriately prioritized overdue inspections and 

ensured additional inspections did not become overdue. 

 
Virginia Final IMPEP Report Page 5 

3.3 Technical Quality of Inspections

The review team evaluated 26 inspection reports that included enforcement documentation and 

letters to licensees, and interviewed the inspectors who were responsible for radioactive 

materials inspections conducted during the review period. The casework examined included a 

cross-section of inspections conducted by five current inspectors and covered a wide variety of 

inspection types involving initial, routine, and special inspections. The casework included 

inspection of various types of programs: academic, broad scope academic, broad scope 

medical, medical private practice, medical institution, high dose-rate remote after-loaders, 

gamma knives, nuclear pharmacies, industrial radiography, and manufacturing and distribution 

licensees. Appendix C lists the inspection casework files reviewed. 

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

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

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

Inspection report documentation supported violations, recommendations made to licensees, 

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

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

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

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

found that outgoing correspondence was marked, as appropriate. 

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

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

Program Manager on multiple occasions over the review period. Since 2011, all inspectors 

have been accompanied annually. The review team noted that during 2011, two of the longer 

term home based staff members were not accompanied. This occurred during a time when the 

Program was in a training mode due to staff losses that occurred just prior to the previous 

review. The Program prioritized activities and these accompaniments were deferred. Both 

inspectors were accompanied prior to 2011 and subsequently with no issues noted. 

The review team accompanied five of the Program’s inspectors in October 2014. The 

inspectors conducted inspections at an industrial radiography licensee, a gamma knife licensee, 

and a broad scope medical and academic licensee. The inspector accompaniments are listed 

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

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

and thorough in their audits of the licensees’ radiation safety and security programs. The 

inspectors conducted interviews with appropriate personnel, observed licensed operations, 

conducted confirmatory measurements, and utilized good health physics practices. The 

inspectors held entrance and exit meetings with the appropriate level of licensee management. 

The review team determined that the inspections were adequate to assess radiological health, 

safety, and security at the licensed facilities. 

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

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

found satisfactory. 
Virginia Final IMPEP Report Page 7 

3.4 Technical Quality of Licensing Actions

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

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

proper radioisotopes and quantities, qualifications of authorized users, adequacy of facilities and 

equipment, adherence to good health physics practices, financial assurance, operating and 

emergency procedures, appropriateness of license conditions, and overall technical quality. 

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

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

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

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

appropriate. 

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

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

new licenses, renewals, decommissioning or termination actions, and amendments. Files 

reviewed included a cross-section of license types–medical diagnostic and therapy, 

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

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

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

All licensing actions are initially entered into the Program’s computer tracking system called 

RAM Database (a Microsoft Access based program). The licensing actions are uploaded to the 

RAM Database system so that information is readily available to the license reviewers. License 

reviewers use checklists and boilerplate licenses specific to the type of licensing actions to 

ensure consistency in licenses. The Program enters information into RAM Database which 

documents license number, staff assignment, type of license action, the date received, and final 

quality assurance review date. The final quality assurance review is performed by the Program 

Manager, who signs each licensing action. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

be found satisfactory.
Virginia Final IMPEP Report Page 7 

3.5 Technical Quality of Incident and Allegation Activities

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

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

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

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

for 14 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 

Program’s response to five allegations involving radioactive materials. The NRC referred two 

allegations to the Commonwealth during the review period. 

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

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

incident meets the reportability thresholds, as established in the Office of Nuclear Material 

Safety and Safeguards Procedure SA-300 “Reporting Material Events,” (SA-300) the Program 

notifies the NRC Headquarters Operations Center and enters the information into NMED, in a 

prompt manner. 

The review team identified 39 radioactive material incidents in NMED for Virginia during the 

review period. The team found that each event requiring reporting was appropriately reported in 

accordance with SA-300. The review team found that all non-reportable incidents in NMED 

were correctly categorized as non-reportable by the Program. The incidents selected for review 

included medical events, lost radioactive materials, damaged equipment, a leaking source, a 

contamination event, and a transportation event that were reported to NMED. The review team 

determined that the Program’s responses to incidents were thorough, complete, and 

comprehensive in all instances. Initial responses were prompt and well-coordinated, and the 

level of effort was commensurate with the health and safety significance. For the 14 cases 

reviewed, the review team determined the Program dispatched inspectors to the site when the 

possibility of an immediate threat to public health and safety existed. 

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

evaluated the casework for the five allegations received by the Program during the review 

period. The review team concluded that the Program consistently took prompt and appropriate 

action in response to concerns raised. The review team noted that the Program thoroughly 

documented the investigations and retained all necessary documentation to appropriately close 

the allegations. The Program notified each alleger of the conclusion of the investigation when 

the identity of the alleger was known. The review team determined that the Program adequately 

protected the identity of allegers. Of the two allegations referred to the Program by the NRC, 

the first one had been reviewed under the Program’s allegation program. The second one 

concerned activities in another state; the Program was waiting for the other state’s 

determination before moving forward on the concern. 

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

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

Allegation Activities, be found satisfactory. 
Virginia Final IMPEP Report Page 8 

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. The 

NRC’s Agreement with the Commonwealth of Virginia does not relinquish authority to regulate a 

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

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

applicable to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

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

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

and 32.1-235. The Department of Health is designated as the Commonwealth’s radiation 

control agency. There have been no changes in legislation affecting the Program over the 

review period. Virginia regulations are not subject to sunset laws. 

4.1.2 Program Elements Required for Compatibility 

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

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

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

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

registration of ionizing radiation machine facilities. 

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

regulations required to be adopted by the Commonwealth under the Commission’s adequacy 

and compatibility policy, and verified the adoption of regulations with data obtained from the 

State Regulation Status Sheet that the Office of Nuclear Material Safety and Safeguards 

maintains. 

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

legally binding requirements no later than three years after the effective date of the NRC’s 

regulations. At the time of this review, Virginia had no overdue regulations. In October 2014, the 

Program submitted proposed regulations for eight amendments to the NRC for review. 

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

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

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

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

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

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

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

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

comment. However, the Commonwealth has a nonstandard regulatory process for “exempt” 
Virginia Final IMPEP Report Page 9 

regulations which the Program can utilize when passing regulations that are necessary to meet 

the requirements of federal law or regulations. This process allows for regulations to be 

promulgated within three to six months. 

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

that Virginia’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, the review team found Virginia’s performance to be 

satisfactory, but needs improvement for the indicator Status of the Materials Inspection 

Program, and satisfactory for the remaining indicators reviewed. Early in the review period, the 

Program experienced a backlog in inspections due, in part, to having a shortage of qualified 

staff to complete inspections within the required timeframe. The Program took corrective action 

to eliminate the backlog of overdue inspections. The MRB determined the Status of the 

Materials Inspection Program should be found satisfactory. The MRB found the Commonwealth 

had addressed the root cause of the overdue inspections and took effective corrective action to 

address the weakness. The review team found, and the MRB agreed, that the recommendation 

from the 2010 IMPEP review regarding the use of qualification journals and the tracking of 

training and qualification of the staff was addressed by the Program and can be closed. 

The review team recommended, and the MRB agreed, that the Virginia Agreement State 

Program be found adequate to protect public health and safety and compatible with the NRC's 

program. The review team recommended the next IMPEP review take place in approximately 

four years. However, the MRB determined the next IMPEP should be in five years since all 

performance indicators were found satisfactory (on two consecutive IMPEP reviews) following 

MRB deliberations. 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Virginia Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Randy Erickson, Region IV Team Leader 

 Technical Quality of Inspections 

 Inspector Accompaniments 

Donna Janda, Region I Technical Staffing and Training 

 Compatibility Requirements 

 Inspector Accompaniments 

Geoffrey Warren, Region III Status of Materials Inspection Program 

 Technical Quality of Incident 

 and Allegation Activities 

Charlene Graham, Ohio Technical Quality of Licensing Actions 
APPENDIX B 

VIRGINIA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML14289A180
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: GE Inspection Services License No.: 760-327-1 

Inspection Type: Routine, Special, Announced Priority: 1 

Inspection Date: 10/11/13 Inspectors: AF, AS 

File No.: 2 

Licensee: J. Core Drilling License No.: 059-354 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/6/14 Inspectors: AS, CC 

File No.: 3 

Licensee: Team Industrial Services License No.: 700-518-1 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 1/7/11 Inspector: BS 

File No.: 4 

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

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/16/11 Inspectors: CC, AF 

File No.: 5 

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

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/6–30/14 Inspector: BS 

File No.: 6 

Licensee: Virginia Commonwealth University License No.: 700-521-1 

Inspection Type: Routine, Special, Announced Priority: 2 

Inspection Date: 10/7–9/10 Inspectors: CC, AF, AS 

File No.: 7 

Licensee: Carolina NDT, Inc. License No.: 191-502-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/6/14 Inspector: KG 

File No.: 8 

Licensee: EADS North America License No.: 059-575-1 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 7/23/13 Inspector: CC 
Virginia Final IMPEP Report Page C. 2 

Inspection Casework Reviews 

File No.: 9 

Licensee: JANX Integrity Group License No.: 590-576-1 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 12/11/12 Inspector: KG 

File No.: 10 

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

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 11/15/10 Inspectors: CC, AF 

File No.: 11 

Licensee: Great Lakes Dredge & Dock Company License No.: 710-533-1 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 6/8/11 Inspector: BS 

File No.: 12 

Licensee: AMEC E&I License No.: NC 032-0082-4 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 10/15/13 Inspector: KG 

File No.: 13 

Licensee: Space Science Services, Inc. License No.: FL 140-2 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Dates: 7/24/14 Inspectors: AS, CC 

File No.: 14 

Licensee: International Isotopes, Inc. License No.: NRC 11-27680-01MD 

Inspection Type: Reciprocity, Announced Priority: 5 

Inspection Date: 5/10/14 Inspector: CC 

File No.: 15 

Licensee: Diamond G Inspection License No.: TX L06229 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/24/13 Inspector: BS 

File No.: 16 

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

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 12/6-8/10 Inspector: KG 

File No.: 17 

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

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/11/13 Inspector: MW 
Virginia Final IMPEP Report Page C. 3 

Inspection Casework Reviews 

File No.: 18 

Licensee: Fauquier Hospital License No.: 059-183-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 9/21/11 Inspector: MW 

File No.: 19 

Licensee: Cardinal Health Nuclear Pharmacy Services License No.: 760-034-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/5–6/11 Inspectors: BS, CC 

File No.: 20 

Licensee: Virginia Cancer Specialists License No.: 600-522-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 8/28/12 Inspector: CC 

File No.: 21 

Licensee: Virginia Institute of Marine Science License No.: 073-221-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 3/8/12 Inspector: BS 

File No.: 22 

Licensee: Virginia Military Institute License No.: 678-440-1 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 4/27/11 Inspector: KG 

File No.: 23 

Licensee: Phillip Morris USA License No.: 760-395-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 4/18–19/12 Inspectors: AF, AS 

File No.: 24 

Licensee: Precision Nuclear Diagnostics License No.: 059-456-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 12/13/13 Inspector: CC 

File No.: 25 

Licensee: Amen Clinic, Inc. License No.: 059-009-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/12/13 Inspector: MW 

File No.: 26 

Licensee: Riverside Tappahannock Hospital License No.: 057-178-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/1/12 Inspectors: AS, CC 
Virginia Final IMPEP Report Page C. 4 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Carolina NDT, Inc. License No.: 191-502-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/6/14 Inspector: KG 

Accompaniment No.: 2 

Licensee: Chesapeake Regional, Riverside, & 

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

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 10/6–30/14 Inspector: BS 

Accompaniment No.: 3 

Licensee: Virginia Commonwealth University License No.: 700-521-1 

Inspection Type: Routine, Special, Announced Priority: 2 

Inspection Date: 10/7-9/10 Inspectors: CC, AF, AS 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Virginia State University License No.: 730-441-1 

Type of Action: Termination Amendment No.: 00 

Date Issued: 7/29/11 License Reviewer: BS 

File No.: 2 

Licensee: Norfolk State University License No.: 710-385-1 

Type of Action: Termination Amendment No.: 02 

Date Issued: 3/22/13 License Reviewer: BS 

File No.: 3 

Licensee: University Nuclear Diagnostics License No.: 760-603-1 

Type of Action: New Amendment No.: 00 

Date Issued: 9/3/14 License Reviewer: AF 

File No.: 4 

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

Type of Action: Renewal Amendment No.: 03 

Date Issued: 12/27/12 License Reviewer: AF 

File No.: 5 

Licensee: Cumberland River Coal Company License No.: 195-301-1 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 6/25/13 License Reviewer: AS 

File No.: 6 

Licensee: Cumberland Resources Corporation License No.: 195-478-1 

Type of Action: Renewal Amendment No.: 03 

Date Issued: 10/6/14 License Reviewer: AS 

File No.: 7 

Licensee: Rad Vets, LLC License No.: 107-601-1 

Type of Action: New Amendment No.: 00 

Date Issued: 7/7/14 License Reviewer: AF 

File No.: 8 

Licensee: Pro-Inspections License No.: 145-600-1 

Type of Action: New Amendment No.: 00 

Date Issued: 5/2/14 License Reviewers: CC/AS 
Virginia Final IMPEP Report Page D. 2 

License Casework Reviews 

File No.: 9 

Licensee: Bremco, LLC License No.: 167-550-1 

Type of Action: Termination Amendment No.: 01 

Date Issued: 6/6/14 License Reviewer: AS 

File No.: 10 

Licensee: Carilion Clinic License No.: 770-051-1 

Type of Action: Amendment Amendment No.: 16 

Date Issued: 5/23/14 License Reviewer: AS 

File No.: 11 

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

Type of Action: Renewal Amendment No.: 10 

Date Issued: 4/18/14 License Reviewer: AF 

File No.: 12 

Licensee: Advex Corporation License No.: 650-254-01 

Type of Action: Renewal Amendment No.: 02 

Date Issued: 4/2/12 License Reviewer: CC 

File No.: 13 

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

Type of Action: Amendment Amendment No.: 07 

Date Issued: 9/17/13 License Reviewer: AF 

File No.: 14 

Licensee: Bon Secours Virginia Health Source, Inc. License No.: 041-404-1 

Type of Action: Amendment Amendment No.: 03 

Date Issued: 7/1/11 License Reviewer: AF 

File No.: 15 

Licensee: PetNet Solutions License No.: 540-560-1 

Type of Action: New Amendment No.: 00 

Date Issued: 6/13/11 License Reviewer: BS 

File No.: 16 

Licensee: Construction Inspection Services License No.: 107-551-1 

Type of Action: Termination Amendment No.: 03 

Date Issued: 7/22/13 License Reviewer: AF 

File No.: 17 

Licensee: Cumberland Resources Corporation License No.: 195-478-1 

Type of Action: Renewal Amendment No.: 02 

Date Issued: 10/9/13 License Reviewer: AS 

 
Virginia Final IMPEP Report Page D. 3 

License Casework Reviews 

File No.: 18 

Licensee: Bon Secours Virginia Health Source, Inc. License No.: 041-404-1 

Type of Action: Amendment Amendment No.: 07 

Date Issued: 4/10/13 License Reviewer: AF 

File No.: 19 

Licensee: Bon Secours Virginia Health Source, Inc. License No.: 041-404-1 

Type of Action: Renewal Amendment No.: 05 

Date Issued: 10/8/12 License Reviewer: AF 

File No.: 20 

Licensee: PetNet Solutions License No.: 540-560-1 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 7/31/12 License Reviewer: CC 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Prince William Hospital License No.: 683-166-1 

Date of Incident: 12/13/12 NMED Log No.: 130115 

Investigation Date: 3/8/13 Type of Incident: Medical Event 

 Type of Investigation: Phone 

File No.: 2 

Licensee: Inova Fairfax Hospital License No.: 610-116-1 

Date of Incident: 3/11/14–3/12/14 NMED Log No.: 140156 

Investigation Date: 4/14/14 Type of Incident: Medical Event 

 Type of Investigation: Phone 

File No.: 3 

Licensee: Sentara Hospitals License No.: 710-189-1 

Date of Incident: 5/4/11 NMED Log No.: 110301 

Investigation Date: 6/13/11 Type of Incident: Medical Event 

 Type of Investigation: Phone 

File No.: 4 

Licensee: ECS Mid-Atlantic, LLC License No.: 770-314-5 

Date of Incident: 8/5/13 NMED Log No.: 130348 

Investigation Date: 8/6/13 Type of Incident: Damage to Equipment 

 Type of Investigation: Phone 

File No.: 5 

Licensee: Geotechnical Environmental Testing Solutions, Inc. License No.: 810-333-1 

Date of Incident: 8/8/13 NMED Log No.: 130355 

Investigation Date: 8/12/13–8/14/13 Type of Incident: Damage to Equipment 

 Type of Investigation: Site 

File No.: 6 

Licensee: Honeywell Resins and Chemicals License No.: 041-341-2 

Date of Incident: 5/15/13 NMED Log No.: 130243 

Investigation Date: 5/16/13 Type of Incident: Damage to Equipment 

 Type of Investigation: Phone 

File No.: 7 

Licensee: American Electric Power License No.: General Licensee 

Date of Incident: 8/12/11 NMED Log No.: 110407 

Investigation Date: 8/30/11 Type of Incident: Damage to Equipment 

 Type of Investigation: Phone 
Virginia Final IMPEP Report Page E. 2 

Incident Casework Reviews 

File No.: 8 

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

Date of Incident: 6/28/11 NMED Log No.: 110509 

Investigation Date: 8/28/11 Type of Incident: Leaking Source 

 Type of Investigation: Phone 

File No.: 9 

Licensee: Chippenham/Johnston Willis Hospitals License No.: 041-058-1 

Date of Incident: 6/23/11 NMED Log No.: 110359 

Investigation Date: 7/15/11 Type of Incident: Contamination Event 

 Type of Investigation: Phone 

File No.: 10 

Licensee: Babcock & Wilcox License No.: 680-028-1 

Date of Incident: 7/31/13 NMED Log No.: 130337 

Investigation Date: 8/1/13 Type of Incident: Transportation 

 Type of Investigation: Phone 

File No.: 11 

Licensee: Carilion Clinic License No.: 770-051-1 

Date of Incident: 2/27/13 NMED Log No.: 130120 

Investigation Date: 2/28/13, 8/13/13–8/29/13 Type of Incident: Medical Event 

 Type of Investigation: Phone, Next Inspection 

File No.: 12 

Licensee: Carilion Clinic License No.: 770-051-1 

Date of Incident: 3/15/13 NMED Log No.: 130135 

Investigation Date: 3/18/13, 8/13/13–8/29/13 Type of Incident: Medical Event 

 Type of Investigation: Phone, Next Inspection 

File No.: 13 

Licensee: Froehling & Robertson, Inc License No.: 760-096-02 

Date of Incident: 9/11/13 NMED Log No.: 130413 

Investigation Date: 9/12/13 Type of Incident: Lost Radioactive Materials 

 Type of Investigation: Site 

File No.: 14 

Licensee: Inova Fairfax Hospital License No.: 610-116-1 

Date of Incident: 7/30/12 NMED Log No.: 120457 

Investigation Date: 7/30/12, 12/16/12–12/17/12 Type of Incident: Lost Radioactive Materials 

 Type of Investigation: Phone, Next Inspection 
ATTACHMENT 

November 25, 2014 Letter from Steven A. Harrison 

Virginia Response to the Draft Report 

ADAMS Accession No.: ML14335A292