November 19, 2012 

Mariannette Miller-Meeks, B.S.N., M.Ed., M.D. 

Director 

Iowa Department of Public Health 

Lucas State Office Building 

321 East 12th Street 

Des Moines, IA 50319 

Dear Dr. Miller-Meeks: 

On November 1, 2012, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Iowa 

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

health and safety and is 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. The review team made no recommendations in regard to program performance by the 

Iowa Agreement State Program during this review. Based on the results of the current IMPEP 

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

approximately 5 years, with a periodic meeting tentatively scheduled for August 2014. The Iowa 

Agreement State Program received an extension of one year for the next IMPEP review based 

on two consecutive IMPEP reviews with satisfactory findings for all the performance indicators 

reviewed. 

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: 

Iowa Final IMPEP Report 

cc w/encl.: Melanie Rasmusson, Chief 

 Bureau of Radiological Health 

 

 Karen Beckley, NV 

 Organization of Agreement States 

 Liaison to the MRB 
Mariannette Miller-Meeks, B.S.N., M.Ed., M.D. 

Director 

Iowa Department of Public Health 

Lucas State Office Building 

321 East 12th Street 

Des Moines, IA 50319 

Dear Dr. Miller-Meeks: 

On November 1, 2012, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Iowa 

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

health and safety and is 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. The review team made no recommendations in regard to program performance by the 

Iowa Agreement State Program during this review. Based on the results of the current IMPEP 

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

approximately 5 years, with a periodic meeting tentatively scheduled for August 2014. The Iowa 

Agreement State Program received an extension of one year for the next IMPEP review based 

on two consecutive IMPEP reviews with satisfactory findings for all the performance indicators 

reviewed. 

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: 

Iowa Final IMPEP Report 

cc w/encl.: Melanie Rasmusson, Chief 

 Bureau of Radiological Health 

 

 Karen Beckley, NV 

 Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: 

See next page 

 ML12310A143 

OFC RI MSSA MSSA MSSA MSSA:D TechEd FSME:D EDO 

NAME MOrendi/via 

email 

LDimmick DWhite PHenderson BMcDermott CPoland MSatorius MWeber 

DATE 11/05/12 11/05/12 11/06/12 11/14/12 11/15/12 11/15/12 11/15 /12 11/19/12 

OFFICIAL RECORD COPY 
Letter to M. Miller-Meeks from Michael F. Weber dated November 19, 2012 

SUBJECT: IOWA 2012 FINAL IMPEP REPORT 

DISTRIBUTION: 

MSSA_Technical_Asst_Resource DCD (SP01) 

RidsEdoMailCenter 

RidsFsmeOd 

RidsOgcMailCenter 

RidsRgn3MailCenter 

RidsRgn4MailCenter 

RidsFsmeDmssa 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

MOrendi, RI/RSAO Commissioner Svinicki 

JLynch, RIII/RSAO Commissioner Apostolakis 

SFlaherty, MN Commissioner Magwood 

MBeardsley, FSME Commissioner Ostendorff 

ABoland, RIII SECY 

PLouden, RIII 

MKotzalas, OEDO 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE IOWA AGREEMENT STATE PROGRAM 

AUGUST 6-10, 2012 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

period of August 6-10, 2012, by a review team composed of technical staff members from the 

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

Based on the results of this review, the review team recommended, and the Management 

Review Board (MRB) agreed, that Iowa’s performance be found satisfactory for all performance 

indicators reviewed. The review team did not make any recommendations regarding program 

performance by the State and determined that the recommendation from the 2007 IMPEP 

review, regarding decommissioning financial assurance, should be closed. 

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

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

NRC's program. The review team recommended, and the MRB agreed, that the next IMPEP 

review take place in approximately five years. 

. 
Iowa Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

was conducted during the period of August 6-10, 2012, by a review team composed of technical 

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

Minnesota. 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 September 15, 2007 to August 10, 2012, were discussed 

with Iowa managers on the last day of the review. 

A draft of this report was provided to Iowa for factual comment on September 6, 2012. The 

State responded by electronic mail dated September 28, 2012. A copy of the State’s response 

is included as an Attachment to this report. A Management Review Board (MRB) met on 

November 1, 2012, to consider the proposed final report. The MRB found the Iowa Agreement 

State Program adequate to protect public health and safety, and compatible with the NRC’s 

program. 

The Iowa Agreement State Program is administered by the Bureau of Radiological Health (the 

Bureau), which is located within the Division of Environmental Health (the Division). The 

Division is part of the Department of Public Health (the Department). An organization chart is 

included as Appendix B. 

At the time of the review, the Iowa Agreement State Program regulated 168 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 Iowa. 

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

non-common performance indicators was sent to the Bureau on May 1, 2012. The Bureau 

provided its response to the questionnaire on July 5, 2012. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML12191A061. 

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

the Bureau’s response to the questionnaire, (2) review of applicable Iowa statutes and 

regulations, (3) analysis of quantitative information from the Bureau’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 Iowa Agreement State Program’s 

performance. 

Section 2.0 of this report covers the Bureau’s actions in response to the recommendation made 

during the previous review. Results of the current review of the common performance indicators 
Iowa Final IMPEP Report Page 2 

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

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review which concluded on September 14, 2007, the review team 

made one performance recommendation regarding the Iowa Agreement State Program. The 

status of the recommendation is as follows: 

“The review team recommends that the State evaluate their decommissioning financial 

assurance program to identify and secure original financial assurance documentation 

from current and future licensees who are required to comply with Iowa’s financial 

assurance requirements.” 

Status: The Iowa Agreement State Program has implemented a procedure, including a 

checklist, to ensure all licenses are compliant with the State’s financial assurance 

requirements. The State also reviewed its licenses to determine need for financial 

assurance and identified four licensees. The review team confirmed all original financial 

assurance documents for these licensees had been obtained and that these documents 

are kept in a secure location. This recommendation is closed.

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review the 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

Considerations central to the evaluation of this indicator include the Bureau’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 Bureau’s questionnaire response relative 

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

and considered workload backlogs. 

The Bureau is composed of several program areas, one of which is the Radioactive Materials 

Program (the Program). The Program is responsible for radioactive materials licensing, 

inspection, and emergency response activities. Two technical staff members left the Program 

during the review period. One of those positions was filled in March 2012 and one position 

was vacant at the time of this review. At the time of the review, there were two technical staff 

members and one administrative staff member with various degrees of involvement in the 

radioactive materials program, totaling approximately 2.2 full-time equivalents (FTE). The 

review team noted that staffing levels did not present any performance issues affecting 

implementation of the Agreement State Program; however, loss of a technical staff member 

could potentially impact the Bureau’s ability to remain current on all regulatory actions. This 

was discussed with Department managers during the exit meeting on August 10, 2012. 
Iowa Final IMPEP Report Page 3 

The Bureau 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 

the 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 review 

team concluded that the Bureau’s training program is adequate to carry out its regulatory duties 

and noted that Iowa management supports the Bureau’s training program. 

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

that Iowa’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 Bureau’s questionnaire response relative to this indicator, data gathered from the 

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

management and staff. 

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

licenses are at least as frequent as similar license types listed in Inspection Manual Chapter 

(IMC) 2800, “Materials Inspection Program.” From the beginning of the review period until 

January 2012, the Bureau inspected licensees more frequently than similar license types. 

Starting in January 2012, the Bureau changed their inspection frequencies to match inspection 

frequencies for similar license types as established in IMC 2800. 

The Bureau conducted 143 Priority 1, 2, and 3 inspections during the review period. None of 

these inspections were conducted overdue by more than 25 percent of the inspection frequency 

prescribed in IMC 2800. The Bureau performed 17 initial inspections during the review period, 

none of which were conducted overdue. Overall, the review team calculated that the Bureau 

performed zero percent of its inspections overdue during the review period. 

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

A sampling of inspection reports indicated that the inspection findings were communicated to 

the licensees within the Bureau’s goal of 30 days after the inspection. 

During the review period, the Bureau granted 192 reciprocity permits, 38 of which were 

candidate licensees for reciprocity inspections 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 Bureau met and exceeded the NRC’s criteria of 

inspecting 20 percent of candidate licensees operating under reciprocity in three of the four 

calendar years covered by the five year review period. For the one year that the Bureau fell 

below the NRC’s criteria of inspecting 20 percent of candidate licensees operating under 

reciprocity, the Bureau inspected 13 percent of candidate licensees for reciprocity. This was 

due to the Bureau needing to focus its attention on other programmatic priorities. 
Iowa Final IMPEP Report Page 4 

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

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

be found satisfactory. 

3.3 Technical Quality of Inspections

The review team evaluated the inspection reports, enforcement documentation, 

inspection field notes, and interviewed inspectors for 22 radioactive materials inspections 

conducted during the review period. The casework reviewed included inspections 

conducted by three Bureau inspectors and covered inspections of various license types, 

including: medical broad scope, medical institutions, radionuclide production (cyclotron), 

industrial radiography, self-shielded irradiators, nuclear pharmacy, mobile nuclear 

medicine, portable gauges, and Increased Security Controls for Large Quantities of 

Radioactive Materials (Increased Controls). Appendix C lists the inspection casework 

files reviewed as well as the results of the inspector accompaniments. 

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

aspects of licensed radiation safety programs. The review team found that inspection reports 

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

ensure that a licensee’s performance with respect to health and safety was acceptable. The 

documentation supported violations, recommendations made to licensees, unresolved safety 

concerns, the effectiveness of corrective actions taken to resolve previous violations and 

discussions held with licensees during exit interviews. 

The inspection procedures utilized by the Bureau are consistent with the inspection guidance 

outlined in IMC 2800. An inspection report is completed by the inspector which is then peer 

reviewed by another inspector. Between July 2011 and March 2012, a second inspector was 

not employed by the program, and thus, the peer review process was suspended. If the peer 

reviewer is qualified for a particular type of inspection, that person signs the “approval” signature 

block on the inspection report. The Bureau Chief accompanied all inspectors on an annual 

frequency. 

The review team determined that the inspection findings were appropriate and prompt 

regulatory actions were taken, as necessary. Inspection findings were clearly stated and 

documented in the reports and sent to the licensees with an appropriate letter detailing the 

results of the inspection. The Bureau issues to the licensee a letter, indicating a clear 

inspection or a Notice of Violation, which details the results of the inspection. Licensees are 

required to respond in writing to cited violations within 30 days. All findings are reviewed by the 

senior health physicist. 

The review team verified that the Bureau maintains an adequate supply of calibrated survey 

instruments to support its inspection program and emergency response activities. Instruments 

are calibrated by the Iowa Homeland Security and Emergency Management Division calibration 

laboratory or by instrument manufacturers. The Bureau uses a database to track each 

instrument, its current location, and next calibration date. 

Accompaniments of two Bureau inspectors were conducted by an IMPEP team member 

during the week of July 23, 2012. The inspectors were accompanied during health and 
Iowa Final IMPEP Report Page 5 

safety inspections of an industrial radiography and a portable gauge licensee. The 

accompaniments are identified in Appendix C. During the accompaniments, the inspectors 

conducted performance-based inspections. The inspectors demonstrated appropriate 

inspection techniques and knowledge of the regulations. 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 and 

safety and security at the licensed facilities. 

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

that Iowa’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 licensing casework and interviewed license reviewers for 

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

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

licenses, eight renewals, three termination actions, and eight amendments. Files reviewed 

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

therapy (including high dose rate remote afterloader, unsealed radioiodine therapy, and 

temporary/permanent implant brachytherapy), industrial radiography, research and 

development, nuclear pharmacy, fixed gauges, and blood irradiators. The casework sample 

represented work from two license reviewers. A list of the licensing casework evaluated is 

provided in Appendix D. 

The review team found that the licensing actions were thorough, complete, consistent, and of 

high quality with health, safety, and security concerns properly addressed. License tie-down 

conditions were stated clearly and were supported by information contained in the file. 

Deficiency letters clearly stated regulatory positions, were used at the proper time, and identified 

substantive deficiencies in the licensees’ documents. Terminated licensing actions were well 

documented, showing appropriate transfer and survey records. License reviewers use the 

Bureau’s licensing guides, policies, checklists, and standard license conditions specific to the 

type of licensing actions to ensure consistency in licenses. 

All qualified license evaluators have signature authority for licensing actions. Licenses are 

signed by the license reviewer and given a “Concurrence” signature by a peer reviewer. During 

the approximately 12-month period in which the Bureau had only one qualified license reviewer, 
Iowa Final IMPEP Report Page 6 

there was only one signature on the licenses. Licenses are issued for a five year period under a 

timely renewal system. 

The review team discovered one new license issued for a high dose rate remote afterloader 

facility that included an authorized user who was added to the license without proper 

documentation to verify the training, experience, and preceptor attestation. The review team 

brought this to the attention of the Bureau, who immediately contacted the licensee and 

determined that this specific authorized user was only listed on this facility’s license and not 

listed on any other license issued by the Bureau, the NRC, or another Agreement State. In 

addition, the Bureau requested this physician’s training, experience, and preceptor authorization 

be sent in and approved by the Bureau before the physician could perform any further cases. 

Upon further discussion with the Bureau staff indicated a misunderstanding regarding preceptor 

attestation requirements, as stated in the Iowa regulations, in situations where a potential 

authorized user is board certified. Due to this misunderstanding, staff indicated no preceptor 

attestation information would be requested for potential authorized users whose submitted 

board certification is recognized by the NRC. While the review team was on-site, the Bureau 

committed to and began reviewing all medical licensing files where authorized users were 

added to a license from 2008 to present. Iowa’s revised medical regulations became effective 

in July 2008 and licensing actions from that point forward would need to document the required 

training and experience for authorized users. Any authorized user added to a license without 

preceptor attestation was contacted for the preceptor documentation. The Bureau completed 

the review of its medical licensing files and obtained from its licensees the preceptor 

statements. The action was completed on October 15, 2012 (ML122890825). 

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

high quality and consistent with the Bureau’s licensing procedures, the State’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 Bureau performs pre-licensing checks of all new applicants. The Bureau’s pre-licensing 

review methods incorporate the essential elements of the NRC’s revised pre-licensing guidance 

to verify that the applicant will use requested radioactive materials as intended. All new 

licensees, not known to the Bureau, receive a pre-licensing site visit which includes an 

evaluation of the applicant’s radiation safety and security programs prior to receipt of the initial 

license. 

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

and Fingerprinting Orders. The review team noted that the State has incorporated the criteria 

for implementing the Increased Controls Order into rule, and uses legally binding license 

conditions that meet the criteria for implementing the fingerprinting requirement, as appropriate. 

The review team analyzed the Bureau’s methodology for identifying those licenses and found 

the rationale was thorough and accurate. The review team confirmed that license reviewers 

evaluated new license applications and license amendments using the same criteria. The 

Bureau requires full implementation of the Increased Controls prior to issuance of a new license 

or license amendment that meets the established criteria. 

The review team examined the Bureau’s implementation of its procedure for the control of 

sensitive information. This procedure addresses the identification, marking, control, handling, 
Iowa Final IMPEP Report Page 7 

preparation, transportation, transmission, and destruction of documents that contain sensitive 

information related to the Increased Controls. Files that contained sensitive information were 

further secured in locked file cabinets. 

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

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

found satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

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

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

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

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

12 radioactive materials incidents. A list of the incident casework examined, with case-specific 

comments, may be found in Appendix E. The review team also evaluated the Bureau’s 

response to five allegations involving radioactive materials, including four allegations referred to 

the State by the NRC during the review period. 

The review team examined the Bureau’s incident and allegation processes, including written 

procedures for handling allegations and incident response, file documentation, notification of 

incidents to the NRC Headquarters Operations Center, and the use of NMED software. When 

notification of an incident or an allegation is received, the Bureau Chief and senior health 

physicist determine the appropriate level of initial response. 

The review team identified 30 radioactive material incidents in NMED for Iowa during the review 

period, of which 12 required reporting. Four non-reportable incidents in Iowa were reviewed for 

reportability and found to be correctly categorized as non-reportable by the Bureau. 

The incidents selected for review included the following categories: lost radioactive material, 

potential overexposure, medical events, equipment failures, leaking source, and facility 

contamination. The review team determined that the Bureau’s response to incidents was 

adequate. Initial responses were prompt and well-coordinated. The Bureau performed on-site 

investigations when incidents were discovered during routine inspections. Three of the 12 

incidents evaluated by the review team were discovered in this manner. 

The review team determined that the Bureau did not perform on-site investigations for three of 

the incidents evaluated during this review. One of the incidents involved a medical procedure in 

which a brachytherapy source was dislodged from a patient. A second medical case, 

concerned a patient treated with iodine-131 who entered a medical center for unrelated 

treatment without notifying the medical center staff of contamination potential. A third incident 

involved a leaking source which caused contamination of equipment in a hot laboratory. Each 

of these incidents presented potential for personnel exposure and an on-site presence by the 

Bureau may have identified causative factors which were not readily apparent to the licensees. 

Rather, the Bureau chose to perform initial investigations of the incidents by telephone and then 

perform a follow-up review of the incident during the next routine inspection. The Bureau Chief 

informed the review team that for future incidents, strong consideration would be given to an onsite response, as opposed to telephone follow-ups. 
Iowa Final IMPEP Report Page 8 

The review team determined that the Bureau took suitable enforcement and follow-up actions to 

reported incidents. If the incident met the reportability thresholds, as established in the Office of 

Federal and State Materials and Environmental Management Programs (FSME) Procedure 

SA-300 “Reporting Material Events,” the Bureau notified the NRC Headquarters Operations 

Center and entered the information into NMED, in a prompt manner. 

In evaluating the effectiveness of the Bureau’s response to allegations, the review team 

evaluated the completed casework for five allegations, including four that the NRC referred to 

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

and appropriate actions in response to concerns raised. One of the allegation investigations 

involved an extensive on site reenactment of an alleged industrial radiography overexposure. 

The review team noted that the Bureau documented the investigations of concerns and retained 

all necessary documentation to appropriately close the allegations. The Bureau notified the 

concerned individuals of the conclusion of their investigations. The review team determined that 

the Bureau adequately protected the identity of concerned individuals. 

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

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

Allegation Activities, be found satisfactory. 

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) LowLevel Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. NRC’s 

Agreement with Iowa does not relinquish regulatory authority for a sealed source and device 

evaluation, low level radioactive waste disposal, or uranium recovery program; therefore, only 

the first non-common performance indicator applied to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Iowa became an Agreement State on January 1, 1986. The current effective statutory authority 

is contained in Chapters 17A and 136C, of the Code of Iowa. The Department is designated as 

the State’s radiation control agency. The Bureau implements the radiation control program. 

The review team noted that legislation affecting the radiation control program in Chapters 

136C.3 subsection 5, 136.8, and 136C.14 subsection 2 was passed during the review period. 

These amendments were minor and cleaned up existing language to reflect modern terms and 

current practice. 

4.1.2 Program Elements Required for Compatibility 

The Iowa regulations governing radiation protection requirements are located in Section 641, 

Chapters 38 through 45 of the Iowa Administrative Code and apply to all ionizing radiation. 

The Bureau requires a license for possession and use of all radioactive material, including 

naturally-occurring materials, such as radium, and accelerator-produced radionuclides. 
Iowa Final IMPEP Report Page 9 

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

process takes one year from the development stage to the final approval. Each rule is filed with 

the office of the administrative rules coordinator which indexes and publishes the rule in the 

Iowa administrative bulletin, after which the rule becomes effective in 35 days. 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. 

The review team noted that the State’s rules and regulations are not subject to Asunset@ laws. 

The State may adopt the regulations of another agency by reference and also has the authority 

to issue other legally binding requirements in lieu of regulations until compatible regulations 

become effective. 

The review team evaluated Iowa’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, Iowa submitted 21 final regulation amendments and one legally 

binding license condition to the NRC 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. The review team noted that, with the most 

recent rulemaking package, the State is up to date on all NRC amendments. A list of 

regulations that are due for adoption can be found at: http://nrcstp.ornl.gov/rss_regamendents.html. 

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

that Iowa’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, Iowa’s performance was found satisfactory for all of 

performance indicators reviewed. The review team did not make any recommendations 

regarding program performance by the State and determined that the recommendation from the 

2007 IMPEP review should be closed. Accordingly, the review team recommended, and the 

MRB agreed, that the Iowa 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 five years. 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Iowa Organization Chart 

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

Monica Orendi, Region I Team Leader 

 Technical Staffing and Training 

 Status of Materials Inspection Program 

 Compatibility Requirements 

James Lynch, Region III Technical Quality of Inspections 

 Technical Quality of Incident and Allegation 

 Activities 

 Inspector Accompaniments 

Sherrie Flaherty, Minnesota Technical Quality of Licensing Actions 
APPENDIX B 

IOWA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML12191A046 
 

 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Element Materials Technology License No.: 0316-1-77-IR1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/24/12 Inspector: RD 

File No.: 2 

Licensee: Foth Infrastructure and Environment, LLC License No.: 0260-1-77-PG 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 7/24/12 Inspector: LW 

File No.: 3 

Licensee: Alliance Imaging, Inc. License No.: 0329-1-00-NV1 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/7/11 Inspector: RD 

File No.: 4 

Licensee: Avera McKennan Hospital License No.: 0358-1-75-M2 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 9/30/09 Inspector: NF 

File No.: 5 

Licensee: Midwest Industrial X-Ray, Inc. License No.: 0075-1-78-IR1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/8/11 Inspector: NF 

File No.: 6 

Licensee: CB & I, Inc. License No.: 0115-1-77-IR1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 4/13/09 Inspector: NF 

File No.: 7 

Licensee: LifeServe Blood Center License No.: 0133-1-77-I1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 7/26/12 Inspectors: RD, LW 

File No.: 8 

Licensee: Hot Shots NM, LLC License No.: 0207-1-82-NP 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/20/08 Inspector: NF 

 
Iowa Final IMPEP Report Page C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: WOS Testing, Inc. License No.: 0253-1-57-IR1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Dates: 6/23-25/09 Inspectors: NF, RD 

File No.: 10 

Licensee: Radiology Group, PC, SC License No.: 0306-1-82-M1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 9/13/11 Inspector: RD 

File No.: 11 

Licensee: Nuclear Sonics Associates, Inc. License No.: 0004-1-77-NV1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 10/31-11/1/07 Inspector: RD 

File No.: 12 

Licensee: Iowa State University License No.: 0014-1-85-AAB 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 4/26-28/11 Inspectors: NF, RD, JC 

File No.: 13 

Licensee: Cardinal Health 414, LLC License No.: 0043-1-77-NP 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/4/09 Inspectors: NF, MR 

File No.: 14 

Licensee: Grinnell College License No.: 0119-1-79-RD2 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/17/11 Inspector: NF 

File No.: 15 

Licensee: Mary Greeley Medical Center License No.: 0049-1-85-M1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/30/12 Inspectors: RD, LW 

File No.: 16 

Licensee: Genesis Medical Center License No.: 0034-1-82-M1 

Inspection Type: Special, Announced Priority: 3 

Inspection Dates: 11/19-20/08 Inspector: NF 

File No.: 17 

Licensee: Clapsaddle-Garber Associates, Inc. License No.: 0120-1-64-PG 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 5/29/12 Inspectors: LW, RD 

 
Iowa Final IMPEP Report Page C.3 

Inspection Casework Reviews 

File No.: 18 

Licensee: The University of Iowa License No.: 0037-1-52-AAB 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 10/11-14/10 Inspectors: RD, NF 

File No.: 19 

Licensee: Iowa Health-Des Moines License No.: 0077-1-77-MET 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 2/21-24/11 Inspectors: RD, JC 

File No.: 20 

Licensee: Midwest Positron Technology, LC License No.: 0308-1-82-PET 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Dates: 5/23-24/11 Inspector: RD 

File No.: 21 

Licensee: Team Industrial Services, Inc. License No.: 9009-1-00-IR1 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 4/13/11 Inspector: RD 

File No.: 22 

Licensee: Mercy Medical Center-Des Moines License No.: 0357-1-77-HDR 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 4/6/09 Inspector: RD 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Foth Infrastructure and Environment, LLC License No.: 0260-1-77-PG 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 7/24/12 Inspector: LW 

Accompaniment No.: 2 

Licensee: Element Materials Technology License No.: 0316-1-77-IR1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/24/12 Inspector: RD 
 

APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: DBI, Inc. License No.: 0350-1-78-IR1 

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

Date Issued: 10/4/07 License Reviewer: NF 

File No.: 2 

Licensee: Siouxland Regional Cancer Center License No: 0359-1-97-M1 

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

Date Issued: 2/6/09 License Reviewer: RD 

File No.: 3 

Licensee: Mary Greeley Medical Center License No.: 0361-1-85-HDR 

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

Date Issued: 5/21/09 License Reviewer: NF 

Comment: Authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 4 

Licensee: Mercy Medical Center License No.: 0339-1-57-HDR 

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

Date Issued: 1/5/11 License Reviewer: RD 

File No.: 5 

Licensee: Radiology Group, PC, SC License No.: 0306-1-82-M1 

Type of Action: Termination Amendment No.: 01 

Date Issued: 4/9/12 License Reviewer: RD 

File No.: 6 

Licensee: Radiology Consultants of Iowa, PLC License No.: 0041-1-57-M1 

Type of Action: Termination Amendment No.: 01 

Date Issued: 6/19/08 License Reviewer: RD 

File No.: 7 

Licensee: Keokuk Steel Casting License No.: 0341-1-56-IR2 

Type of Action: Termination Amendment No.: 01 

Date Issued: 1/24/08 License Reviewer: RD 

 
Iowa Final IMPEP Report Page D.2 

Licensing Casework Reviews 

File No.: 8 

Licensee: Catholic Health Initiatives – Iowa Corp License No.: 0124-1-77-M1 

Type of Action: Amendment Amendment No.: 06 

Date Issued: 7/17/12 License Reviewer: RD 

File No.: 9 

Licensee: Ottumwa Regional Health Center License No.: 0016-1-90-M1 

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

Date Issued: 12/12/07 License Reviewer: RD 

File No.: 10 

Licensee: Avera McKennan License No.: 0315-1-00-NV1 

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

Date Issued: 1/7/08 License Reviewer: RD 

File No.: 11 

Licensee: Hot Shots NM, LLC License No.: 0289-1-57-NP 

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

Date Issued: 11/30/09 License Reviewer: RD 

File No.: 12 

Licensee: Midwest Positron Technology, LC License No.: 0308-1-82-PET 

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

Date Issued: 7/30/12 License Reviewer: RD 

File No.: 13 

Licensee: Lifeserve Blood Center License No.: 0281-1-97-I1 

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

Date Issued: 1/23/09 License Reviewer: NF 

File No.: 14 

Licensee: University of Iowa License No.: 0037-1-52-AAB 

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

Date Issued: 4/1/08 License Reviewer: NF 

File No.: 15 

Licensee: Great River Medical License No.: 0022-1-29-M1 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 6/11/12 License Reviewer: NF 

File No.: 16 

Licensee: Mercy Medical License No.: 0017-1-57-MET 

Type of Action: Amendment Amendment No.: 08 

Date Issued: 3/5/12 License Reviewer: RD 

 
Iowa Final IMPEP Report Page D.3 

Licensing Casework Reviews 

File No.: 17 

Licensee: Iowa Health – Des Moines License No.: 0310-1-77-HDR 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 9/26/11 License Reviewer: RD 

File No.: 18 

Licensee: St. Anthony Regional Medical Center License No.: 0313-1-14-HDR 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 5/12/11 License Reviewer: NF 

File No.: 19 

Licensee: Northern Shared Medical Services, Inc License No.: 0298-1-00-NV1 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 8/5/11 License Reviewer: RD 

File No.: 20 

Licensee: Midwest Industrial X-Ray, Inc License No.: 0075-1-78-IR1 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 6/27/11 License Reviewer: RD 

File No.: 21 

Licensee: SSAB Iowa, Inc License No.: 0259-1-70-FG 

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

Date Issued: 7/22/10 License Reviewer: NF 

File No.: 22 

Licensee: Siouxland Regional Cancer Center License No.: 0359-1-97-M1 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 3/16/10 License Reviewer: RD 

File No.: 23 

Licensee: Mercy Medical Center License No.: 0339-1-57-HDR 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 9/26/08 License Reviewer: RD 
 

APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Pharmacy Services of the Quad Cities License No.: 0207-1-82-NP 

Date of Incident: 10/4/07 NMED No.: 070617 

Investigation Date: 10/5/07 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 2 

Licensee: University of Iowa License No.: 0037-1-52-AAB 

Date of Incident: 10/19/07 NMED No.: 070654 

Investigation Date: 10/19/07 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

 Comment: The State did not perform an on-site inspection. 

File No.: 3 

Licensee: Keokuk Steel Castings License No.: 3325-1-56-XRF 

Date of Incident: 2/26/08 NMED No.: 080775 

Investigation Date: 11/6/08 Type of Incident: Lost Source 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: Marshalltown Medical & Surgical Center License No.: 0053-1-64-M1 

Date of Incident: 5/3/09 NMED No.: 090543 

Investigation Date: 5/28/09 Type of Incident: Leaking Source 

 Type of Investigation: Telephone 

 Comment: The State did not perform an on-site inspection. 

File No.: 5 

Licensee: SSAB Iowa, Inc. License No.: 0259-1-70-FG 

Date of Incident: 1/7/10 NMED No.: 100032 

Investigation Date: 1/12/10 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

 
Iowa Final IMPEP Report Page E. 2 

Incident Casework Reviews 

File No.: 6 

Licensee: Radiology Group BC License No.: 0306-1-82-M1 

Date of Incident: 8/7/10 NMED No.: 100420 

Investigation Date: 8/17/10 Type of Incident: Overexposure 

 Type of Investigation: Telephone 

 

 Comment: The State did not perform an on-site inspection. 

File No.: 7 

Licensee: Tjaden Biosciences License No.: 0344-1-29-MD 

Date of Incident: 12/3/09 NMED No.: 100502 

Investigation Date: 10/7/10 Type of Incident: Contamination 

 Type of Investigation: On-Site 

File No.: 8 

Licensee: Mercy Medical Center License No.: 0339-1-57-HDR 

Date of Incident: 2/10/11 NMED No.: 110104 

Investigation Date: 2/11/11 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 9 

Licensee: Midwest Industrial X-Ray License No.: 0075-1-78-IR1 

Date of Incident: 6/24/11 NMED No.: 110323 

Investigation Date: 6/24/11 Type of Incident: Equipment Failure 

 Type of Investigation: On-Site 

File No.: 10 

Licensee: Curwood, Inc. License No.: 3003-1-77-FG 

Date of Incident: 11/2/11 NMED No.: 110590 

Investigation Date: 11/2/11 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 11 

Licensee: MidAmerican Energy License No.: 0040-1-70-FG 

Date of Incident: 12/27/11 NMED No.: 120012 

Investigation Date: 12/27/11 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 12 

Licensee: SSAB Iowa, Inc. License No.: 0259-1-70-FG 

Date of Incident: 5/17/12 NMED No.: 120420 

Investigation Date: 7/12/12 Type of Incident: Equipment Failure 

 Type of Investigation: On-Site 

Comment: This incident was discovered during a routine inspection but was not 

mentioned in the inspection report.
ATTACHMENT 

September 28, 2012 email from Melanie Rasmusson 

Iowa’s Response to the Draft Report 

ADAMS Accession No.: ML12277A067