UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

REGION I 

2100 RENAISSANCE BLVD., SUITE 100 

KING OF PRUSSIA, PA 19406-2713 

July 19, 2016 

Stephen Gavitt, CHP, Director 

Bureau of Environmental Radiation Protection 

Department of Health 

Empire State Plaza, Corning Tower – 12th Floor 

Albany, NY 12237 

Dear Mr. Gavitt: 

A periodic meeting with you and your staff was held on May 5, 2016. The purpose of this 

meeting was to review and discuss the status of the New York Agreement State Program. The 

U.S. Nuclear Regulatory Commission (NRC) was represented by Joseph Nick, Lisa Dimmick, 

Robin Elliott, and me. 

I have completed and enclosed a general meeting summary. If you feel that our conclusions do 

not accurately summarize the meeting discussion, or have any additional remarks about the 

meeting in general, please contact me at (610) 337-5371 or via e-mail at Donna.Janda@nrc.gov

to discuss your concerns. 

 Sincerely, 

 /RA/ 

 Donna M. Janda 

 Regional State Agreements Officer 

 Division of Nuclear Materials Safety 

 

Enclosure: 

Periodic Meeting Summary for New York 

 Department of Health 

 
July 19, 2016 

Stephen Gavitt, CHP, Director 

Bureau of Environmental Radiation Protection 

Department of Health 

Empire State Plaza, Corning Tower – 12th Floor 

Albany, NY 122 

Dear Mr. Gavitt: 

A periodic meeting with you and your staff was held on May 5, 2016. The purpose of this 

meeting was to review and discuss the status of the New York Agreement State Program. The 

U.S. Nuclear Regulatory Commission (NRC) was represented by Joseph Nick, Lisa Dimmick, 

Robin Elliott, and me. 

I have completed and enclosed a general meeting summary. If you feel that our conclusions do 

not accurately summarize the meeting discussion, or have any additional remarks about the 

meeting in general, please contact me at (610) 337-5371 or via e-mail at Donna.Janda@nrc.gov

to discuss your concerns. 

 Sincerely, 

 /RA/ 

 Donna M. Janda 

 Regional State Agreements Officer 

 Division of Nuclear Materials Safety 

 

Enclosure: 

Periodic Meeting Summary for New York 

 Department of Health 

Distribution: 

L. Dimmick, NMSS D. Collins, NMSS P. Michalak, NMSS 

P. Henderson, NMSS M. Ford, RI DNMS D. Janda, RI DNMS 

J. Trapp, RI DNMS J. Nick, RI DNMS R. Elliott, RI DNMS 

SUNSI Review Complete: DMJ (Reviewer’s Initials) 

\\nrc.gov\nrc\R1\Shared\State Agreement Files\New York\DOH May 2016 Periodic Meeting Summary and Transmittal 

Letter.docx ML16202A292 

After declaring this document “An Official Agency Record” it will be released to the Public. 

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy 

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OFFICE DNMS/RI 

NAME Janda/dmj 

DATE 07/19/16 

 
AGREEMENT STATE PERIODIC MEETING SUMMARY FOR 

NEW YORK DEPARTMENT OF HEALTH 

BUREAU OF ENVIRONMENTAL RADIATION PROTECTION 

DATE OF MEETING: May 5, 2016 

U.S. Nuclear Regulatory 

Commission (NRC) Attendees 

New York Department of Health Attendees 

Donna Janda, State Agreements 

Officer, Region I 

Stephen Gavitt, Director, Bureau of Environmental 

Radiation Protection 

Joseph Nick, Deputy Director, Division 

of Nuclear Materials Safety, Region I 

Robert Dansereau, Assistant Director, Bureau of 

Environmental Radiation Protection 

Lisa Dimmick, Senior Health Physicist, 

Agreement State Programs Branch, 

Office of Nuclear Material Safety and 

Safeguards 

Daniel Samson, Chief, Radioactive Materials 

Section 

Robin Elliott, Acting State Agreements 

Officer, Division of Nuclear Materials 

Safety, Region I 

 

DISCUSSION: 

The agencies which comprise the New York Agreement State program (Program) are the New 

York State Department of Health (DOH), which has jurisdiction over industrial uses of 

radioactive material throughout the State as well as medical, academic, and research uses 

outside the five boroughs of New York City; New York State Department of Environmental 

Conservation (DEC), which has jurisdiction throughout the State over discharges of radioactive 

material to the environment, including releases to the air and water, and the disposal of 

radioactive waste in the ground; and New York City Department of Health and Mental Hygiene 

(NYC), which has jurisdiction over medical, academic, and research uses of radioactive material 

within the five boroughs of New York City. During the March 2014 Integrated Materials 

Performance Evaluation Program (IMPEP) review of the New York Program, the review team 

found the State’s performance satisfactory for five performance indicators; satisfactory, but 

needs improvement, for the performance indicator, Technical Staffing and Training; and 

unsatisfactory for the performance indicator, Compatibility Requirements. The review team 

found the performance indicator, Technical Quality of Licensing Actions, to be satisfactory, but 

needs improvement; however, the Management Review Board (MRB) determined this indicator 

should be found satisfactory. The review team made three recommendations regarding 

program performance in technical staffing, technical quality of licensing, and compatibility 

requirements, and determined that the six recommendations from the 2011 IMPEP review, 

regarding reciprocity inspections, development of an action plan to adopt NRC regulations, and 

incident reporting and incident procedures, should be closed. 

On August 4, 2014, the MRB found the Program to be adequate to protect public health and 

safety and not compatible with NRC’s program. The MRB commended the Program for 

progress made under the indicator, Technical Quality of Incident and Allegation Activities, where 

performance was improved from unsatisfactory to satisfactory during the review period, and for 

the progress made in adopting several overdue rules. As a result, the MRB directed that the 

period of Heightened Oversight be discontinued and a period of Monitoring be initiated. The 
New York Department of Health 

Periodic Meeting Summary 2 

MRB directed that quarterly calls be conducted between the New York and NRC staffs. The 

MRB also directed that a Periodic Meeting be conducted in approximately March 2016. This 

report is a summary of the Periodic Meeting held with DOH. 

TOPICS COVERED DURING THE MEETING INCLUDED: 

Program Strengths 

• Experienced, well-trained staff 

• Good Program support from senior management; meet weekly with Division Director to 

review issues 

Program Challenges 

• Filling vacancies is a challenge due to the State hiring freeze. A vacancy waiver is 

needed to hire each new staff member. 

• No longer having dedicated IT support for the Program; IT support has now been 

consolidated into one State IT function 

Feedback on the NRC’s Program 

DOH is interested in having a discussion with the NRC Office of International Programs (OIP) 

regarding oversight of radioactive material that is imported into the United States and 

misplaced/lost during transit. DOH is not informed of these shipments and would like to discuss 

their concerns with OIP. All parties agree that a conference call with NRC and DOH should be 

arranged to discuss the matter. 

The Program managers noted that has been working with the Environmental Protection Agency, 

the National Park Service, and NRC to resolve jurisdiction issues related to cleanup activities at 

the Great Kills National Park site. 

Due to the limited number of NRC courses and participants per course and the funding issues 

NRC is facing with Agreement State training, the Program managers mentioned that it can be 

challenging to meet Program training needs. 

The Program appreciates the opportunity to comment on NRC documents; however, sometimes 

the comment period is not long enough (e.g., 30-day comment period for a large document). 

The Program would like to see a comment period that is appropriate for and based on the length 

of the document. 

Organization 

The Program is administered by the Bureau of Environmental Radiation Protection (the Bureau) 

which is located in the Division of Environmental Health Investigation (the Division). The 

Division is part of the Center for Environmental Health (the Center) within the DOH. Since the 

2014 IMPEP review, the Center has dissolved one division and now operates with two divisions. 

Within the Bureau, there is no longer a field operations supervisor position. Those job duties 

are now split between the Radioactive Materials Section Chief and the X-Ray Section Chief. 
New York Department of Health 

Periodic Meeting Summary 3 

Program Budget/Funding 

The Program reported that there has not been a fee increase since 2000-2001. The Program is 

interested in raising licensee fees but has not received support for a fee increase. Licensee 

fees are placed into a restricted fund; however, approval is required prior to spending the funds. 

Technical Staffing and Training (2014 IMPEP: Satisfactory, but Needs Improvement) 

At the time of the periodic meeting, the Program had approximately 12.0 full-time equivalents 

supporting the radioactive materials program including one recent vacant position. No other 

staff have left the Program since the 2014 IMPEP review. The Program anticipates some 

retirements in the next few years and will handle them through the same vacancy waiver 

process as the current practice. 

The Program has incorporated the new requirements of NRC Inspection Manual Chapter 1248 

into their qualification program for radioactive materials licensing and inspection staff. 

The 2014 IMPEP review team made one recommendation for DOH in this indicator: 

Recommendation: The review team recommends that the DOH continue to pursue vacancy 

waivers and implement a strategy to address current and future staffing vacancies in order to 

maintain effectiveness. 

Status: The Program reported that the Center has recently approved all nine vacancy waivers. 

Four of the positions are for new technical staff (two senior level and two trainee positions). 

One position is the change of the Acting Section Chief to a permanent Section Chief. Four 

positions are administrative. The Program has started the hiring process and anticipates having 

the new staff by the end of June. In addition to the new staff, three provisional staff have been 

made permanent staff. The Program has established a new higher grade medical physicist job 

title and has moved the current medical physicist on staff into that position. 

Status of Materials Inspection Program (2014 IMPEP: Satisfactory) 

The Program reported that it completed four routine inspections overdue in 2015 according to 

the priorities established in NRC Inspection Manual Chapter 2800. No initial inspections were 

completed overdue since the 2014 IMPEP review. All initial inspections are completed within 

six months of license issuance. The Program performed 7 reciprocity inspections in 2015, 

which was approximately 18 percent of candidate reciprocity licensees. Performing reciprocity 

inspections is a challenge for the DOH due to travel budget restraints. Out-of-state licensees 

have a 30-day limit on working under reciprocity in New York. After 30 days, the licensee must 

have a specific license to work in the State. 

Technical Quality of Inspections (2014 IMPEP: Satisfactory) 

With the dissolution of the Field Operations Supervisor position, the Radioactive Materials 

Section Chief now reviews inspection reports. The Program reported that it did not meet its goal 

in 2015 of performing a supervisory inspection accompaniment for each qualified inspector due 

to focusing on training new inspectors. The Program plans to schedule the 2016 supervisor 

accompaniments between the Radioactive Materials Section Chief, the Assistant Director and 

other senior inspectors. The Program will perform Part 37 inspections as part of the routine 
New York Department of Health 

Periodic Meeting Summary 4 

inspections. The licenses which were amended to include the Part 37 license condition were 

mailed to the licensees along with guidance on the new Part 37 requirements. Now that DOH 

will be performing inspections at Category 1 licensees, the Program would like to receive 

information on the most recent NRC inspection at these facilities. This request is being 

reviewed by NMSS and the NRC Regional Office. 

Technical Quality of Licensing Actions (2014 IMPEP: Satisfactory) 

At the time of the Periodic Meeting, the Program reported having approximately 1,000 specific 

radioactive materials licenses. The Program uses pre-licensing guidance for all licensing 

actions and recently denied one license application request based on the applicant’s failure to 

provide the necessary information needed to complete a review of the application. Licenses are 

issued for a 10-year period. The Program continues to make progress addressing the backlog 

of license renewal actions. Approximately 150 license renewal applications have been pending 

for greater than one year (down from 187 actions identified during the 2014 IMPEP review). 

Technical Quality of Incidents and Allegation Activities (2014 IMPEP: Satisfactory) 

Since the 2014 IMPEP review, DOH has reported 12 events involving radioactive materials to 

the NRC. In addition, DOH received two allegations from NRC since the last review. All cases 

were investigated and are either closed out or still under investigation by the Program. 

Compatibility Requirements (2014 IMPEP: Unsatisfactory) 

The 2014 IMPEP review team made one recommendation in this indicator: 

Recommendation: The review team recommends that the Program make appropriate 

regulatory changes to resolve NRC-generated comments as noted in regulation review letters, 

and adopt NRC regulations in accordance with the current NRC policy on adequacy and 

compatibility. 

Status: The DOH regulations related to the radioactive materials program are found in Part 16 

of the New York State Health Code. The DOH has 14 NRC amendments overdue for adoption. 

To address the overdue regulations and the outstanding comments to final regulations not yet 

addressed, the Program plans to incorporate NRC regulations by reference. The Program is 

working directly with their legal staff in developing the adopted regulations. The DOH has 

already adopted 10 CFR Part 35 by reference. Once the adopted regulations are ready for 

adoption, Part 16 will be repealed and replaced with the adopted regulations. New York 

Executive Laws prohibit open ended adoption by reference; therefore, each time NRC issues 

new regulation amendments, DOH will need to update their regulations with the changes. 

Sealed Source and Device Evaluation (SS&D) Program (2014 IMPEP: Satisfactory) 

The DOH is considering returning the SS&D program to the NRC. No SS&D actions have been 

issued since the last Monitoring call in January 2016. The Program has two trained staff 

members who perform SS&D reviews. 

 
New York Department of Health 

Periodic Meeting Summary 5 

Current State Initiatives 

The Program reported that it has implemented a new payment system for licensee fees as part 

of a DOH-wide initiative. 

Large, Complicated, or Unusual Authorizations for Use of Radioactive Material 

The Program recently authorized the use of a new Icon gamma stereotactic radiosurgery 

device. 

State’s Mechanisms to Evaluate Performance 

The Section Chief reviews all licensing actions and inspection reports. Program managers hold 

weekly meetings to review and discuss workload and review inspection and licensing timeliness. 

The Program’s database will be updated with new fields to track the length of time licensing 

actions are with the license reviewer. Higher priority assignments will be metrics set to ensure 

the actions are completed in a timely manner. 

CONCLUSIONS: 

The DOH Agreement State Program continues to be an effective, well maintained program. At 

the time of the Periodic Meeting, the Program received vacancy waiver approval for nine 

positions and was in the process of filling those positions. The Program is effectively managing 

its licensing and inspection activities and responds to incidents and allegations as appropriate. 

The Program continues to address the backlog in license renewal applications. The Program is 

planning to address its overdue regulations by adopting NRC regulations by reference and is 

utilizing its legal staff in the adoption process. 

NRC staff recommends that the next IMPEP review be conducted as scheduled in March 2018.