UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION IV

1600 E. LAMAR BLVD.

ARLINGTON, TX 76011-4511

June 22, 2016

Kimberly Steves, Director

Radiation Control Program

Department of Health and Environment

1000 SW Jackson, Suite 330

Topeka, KS 66612

Dear Ms. Steves, 

A periodic meeting with you and your staff was held on June 2, 2016. The purpose of this 

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

scope of the meeting was limited to activities conducted by the Kansas Radiation Control 

Program. The U.S. Nuclear Regulatory Commission was represented by Linda Howell and me.

I have completed and enclosed a general meeting summary, including any specific actions 

resulting from the discussions. A Management Review Board (MRB) meeting to discuss the 

outcome of the periodic meeting has been scheduled for August 30, 2016 at 1:00 pm (EDT). 

Call-in information for the MRB will be provided in a separate transmission. 

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 (817) 200-1116, or 

by email at Binesh.Tharakan@nrc.gov.

Sincerely,

/RA/

Binesh K. Tharakan, CHP

Regional State Agreements Officer

Division of Nuclear Materials Safety

Enclosure: 

Periodic Meeting Summary
Kimberly Steves, Director

Radiation Control Program

Department of Health and Environment

1000 SW Jackson, Suite 330

Topeka, KS 66612

Dear Ms. Steves, 

A periodic meeting with you and your staff was held on June 2, 2016. The purpose of this 

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

scope of the meeting was limited to activities conducted by the Kansas Radiation Control 

Program. The U.S. Nuclear Regulatory Commission was represented by Linda Howell and me.

I have completed and enclosed a general meeting summary, including any specific actions 

resulting from the discussions. A Management Review Board (MRB) meeting to discuss the 

outcome of the periodic meeting has been scheduled for August 30, 2016 at 1:00 pm (EDT). 

Call-in information for the MRB will be provided in a separate transmission. 

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 (817) 200-1116, or 

by email at Binesh.Tharakan@nrc.gov.

Sincerely,

/RA/

Binesh K. Tharakan, CHP

Regional State Agreements Officer

Division of Nuclear Materials Safety

Enclosure: 

Periodic Meeting Summary

DISTRIBUTION: (SP08)

M. Shaffer, RIV

L. Howell, RIV

D. Collins, NMSS

P. Michalak, NMSS

P. Henderson, NMSS

R. Erickson, RSAO

L. Dimmick, NMSS

L. Roldan, NMSS

S:\DNMS\!SAO\Periodic Meetings\2016\Kansas\2016 Kansas Periodic Meeting Summary.docx ML16169A007

X SUNSI Review

By: BKT

ADAMS

X Yes 

No

X Publicly Available 

 Non-Publicly 

Available

X Non-Sensitive

 Sensitive

Keyword:

OFFICE RIV:RSAO

NAME BKTharakan

SIGNATURE

DATE 6/22/2016

OFFICIAL RECORD COPY
PERIODIC MEETING SUMMARY FOR THE

KANSAS AGREEMENT STATE PROGRAM

DATE OF MEETING: JUNE 2, 2016

U.S. Nuclear Regulatory 

Commission (NRC) Attendees

Kansas Department of Health and Environment

(KDHE)

Binesh Tharakan

Regional State Agreements Officer

Region IV

Kim Steves, Director

Kansas Radiation Control Program

Linda Howell, Deputy Director, 

Division of Nuclear Materials Safety, 

Region IV

Jason Barney, Supervisor

Radioactive Materials and X-ray Section

Judee Walden, Lead Worker

Radioactive Materials Section

Ashley Goss, Director, Bureau of Community Health 

Systems

DISCUSSION:

Kansas became an Agreement State on January 1, 1965. The Kansas Agreement State 

Program is administered by the Radioactive Materials Section (the Section) of the Kansas

Radiation Control Program (the Program). The Program is located within the Bureau of 

Community Health Systems (the Bureau), which is part of the Kansas Department of Health and 

Environment (the Department).

The 2014 Integrated Materials Performance Evaluation Program (IMPEP) review of the Kansas

Agreement State Program found Kansas’ performance satisfactory for four out of six 

performance indicators reviewed: Technical Staffing and Training, Status of the Materials 

Inspection Program, Technical Quality of Inspections, and Compatibility Requirements. Kansas’ 

performance for the other two indicators, Technical Quality of Licensing Actions and Technical 

Quality of Incidents and Allegation Activities, was found satisfactory, but needs improvement. 

The 2014 IMPEP review team made one recommendation for the Program in Technical Quality 

of Licensing Actions. The review team recommended that the State review all active medical 

licenses and verify that previously approved authorized physician users have the proper board 

certification or training requirements, and preceptor attestation, and develop and implement a 

process that will ensure proper verification and documentation of user qualifications for 10 CFR 

35.300 (KAR 28-35-264) uses of byproduct material.

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

that the Kansas Agreement State Program be found adequate to protect public health and 

safety, and compatible with the NRC's program. The MRB also agreed that the next IMPEP 

review should take place in 4 years and a periodic meeting be held 2 years from the 2014 

IMPEP.

On June 2, 2016, the NRC conducted the periodic meeting with the Kansas Agreement State 

staff and managers listed above. The following report summarizes the periodic meeting.
Kansas Department of Health and Environment

Periodic Meeting Summary Page 2

TOPICS COVERED DURING THE MEETING INCLUDED:

Program Challenges

In 2015, the Section Supervisor and the Program Director left for employment elsewhere. A

new Program Director and Section Supervisor were promoted from within the Department. A 

replacement materials inspector with a health physics background was hired from outside the 

Department. The Program reported that it is very difficult to recruit and retain qualified 

inspectors, partially due to State budget problems which have resulted in no pay increases over 

the past several years. However, there has not been significant turnover in the current staff, 

other than the one new hire. The Program is concerned that two of the five current technical 

staff could retire in a few years and that recruiting technically qualified individuals to fill the 

vacancies could become a challenge.

The new Program management inherited the 10 CFR Part 37 Implementation and discovered 

the regulations were only partially completed. This created challenges for the program because 

two sets of staff were working on different parts of the new regulations and it was difficult to 

determine which parts were complete and which ones still needed work. The final Part 37 

regulations have been completed by the new Program management. The rules process can be 

lengthy process sometimes taking upwards of a year to complete. At the time of the periodic 

meeting, the final Part 37 regulations were at the Kansas Attorney General’s office for final 

approval. Due to the transition in Program management and the lengthy rules process, the 

Program implemented 10 CFR Part 37 through a license condition. On March 11, 2016, the 

Program issued an information notice to the affected licensees indicating that their license was 

being amended on March 19, 2016, to adopt 10 CFR Part 37 by reference. The affected 

licensees are required to be in compliance with 10 CFR Part 37 no later than March 19, 2016.

Feedback on NRC’s Program

In 2012, Kansas suggested that the NRC consider adding more specific information to the email 

subject line to describe what is in the attachment when the NRC sends notices or letters to the 

Agreement States. In addition, if the NRC is requesting a response with a due date, it should be 

clearly stated in the subject line and at the beginning of the respective document instead of at 

the end of the document. The Program has observed the amount of emails with requested 

responses has increased. These requests place significant resource burdens on the Program 

and use time that is much needed for other duties pertaining to the radioactive materials 

program. Kansas requests that the NRC attempt to lower the number of such requests it 

routinely sends.

The Program would like to acknowledge the NRC staff for doing an excellent job of 

communicating and coordinating with the new Program Director and Section Supervisor. 

Kansas specifically expressed appreciation for the help and support provided by the Region IV 

State Liaison Officer, Region IV State Agreements Officers, and the NRC Headquarters 

Agreement State Regulations Resource staff.

Program Reorganizations

The Department has reorganized since the 2014 IMPEP review. There is a new Secretary for 

Health and Environment. The Bureau of Environmental Health was dissolved and the Kansas 

Radiation Control Program was moved into the Bureau of Community Health Systems. There is 

also a new Bureau Director, who has very little experience with radioactive materials. The 
Kansas Department of Health and Environment

Periodic Meeting Summary Page 3

asbestos abatement program is no longer part of the Radiation Control Program. More recently, 

in 2016, job titles within the Section changed from Environmental Scientist (I-IV) to 

Environmental Compliance/Regulatory Specialist or Environmental Specialist. Regulations 

development was moved directly under the Section Supervisor instead of being developed by 

support organization personnel.

Program Budget/Funding

There have been no changes to the budget since the last IMPEP. The Program remains fully 

fee funded from a dedicated fee fund. Estimated budget projections for the near term indicate a 

solid base of funding for the Program. A potential increase in fees is estimated to be needed in 

three to four years, and will require a regulatory change. The Program is in discussions with 

Department management to develop a strategy to propose future changes to the fee structure.

Technical Staffing and Training (2014 IMPEP: Satisfactory)

At the time of the periodic meeting, the Section was composed of 5 technical positions, one

supervisor, and one director, with additional administrative support to implement the Agreement 

State Program. The Section performs materials licensing, inspection, compliance, and 

emergency response functions. The Program reported that the five technical staff positions are 

adequate to implement the radioactive materials program. Since the last IMPEP review, the 

Section hired one technical staff member with an advanced degree in health physics to replace 

the position vacated by the current Section Supervisor.

At the time of the periodic meeting, there were no vacancies in the Section. However, when 

vacancies do occur, it can negatively impact productivity. To offset any negative impacts from 

vacancies, the Section cross-trains other Program staff by sending them to NRC-sponsored 

training, as needed. The Section reports that the cross-training of other Program staff should 

lessen impacts from future retirements and staff turnover within the Section.

At the last IMPEP review, the Section maintained a documented training and qualification 

program that is compatible with NRC’s Inspection Manual Chapter (IMC) 1248, “Qualification 

Programs for Federal and State Materials and Environmental Management Programs.” The 

Section reported that it continues to maintain a compatible training program and that the 

documented training program is reviewed and updated annually.

Status of Materials Inspection Program (2014 IMPEP: Satisfactory)

The Program conducts most inspections at the same frequency as the NRC. For academic 

broad scope, medical broad scope, medical private practice, portable gauge, commercial 

radiopharmacy, research and development, and well logging licensees, the Program conducts 

inspections more frequently than required by IMC 2800.

The Program reported that no initial or routine priority 1, 2, or 3 inspections were conducted 

overdue since the last IMPEP review and that none were currently overdue.

The last IMPEP report stated that the Program did not inspect at least 20 percent of candidate 

reciprocity licensees in each year of the review period. The Program modified its “Inspection 

Priority System” procedure to specifically include reciprocity inspections. The Program 

generates a list of candidate reciprocity licensees and assigns them to individual inspectors. 

The inspectors are responsible for completing their assigned reciprocity inspections. At the time 
Kansas Department of Health and Environment

Periodic Meeting Summary Page 4

of periodic meeting, the Program reported that it inspected 8 of 16 total candidate reciprocity 

licensees, and at least 20 percent each year, since the last IMPEP review.

Technical Quality of Inspections (2014 IMPEP: Satisfactory)

The Section reported that supervisory accompaniments of the Section’s inspectors in 2015 were 

performed by the lead worker. The Section Supervisor is scheduled to perform the supervisory 

accompaniments in 2016. Prior to 2015, the supervisory accompaniments were performed by 

the previous Section Supervisor. The Section also recently completed a revision of the 

inspection procedures and revised the form to document the supervisory accompaniments.

The Section reported that some challenges affecting the inspection program included the 

geographic location of licensees; reciprocity inspections, especially mobile medical licensees 

entering the western part of Kansas; and mentoring/training new inspectors.

Technical Quality of Licensing Actions (2014 IMPEP: Satisfactory, but Needs Improvement)

At the time of the periodic meeting, the Kansas Agreement State Program regulated 275 

specific licensees. Licenses are created and tracked using an internal database. Once 

licensing actions are completed, they are issued under the Section Supervisor’s signature. The 

Section has internal procedures for processing licensing actions based on the guidance 

contained in NRC’s NUREG-1556 series, “Consolidated Guidance about Materials Licenses.” 

Since the 2014 IMPEP review, the Section has completed 452 licensing actions, of which, about 

10 were complex licensing actions for large broad scope medical and academic facilities, or 

large decommissioning projects.

The 2014 IMPEP review team found repeated examples of licensing actions where the 

appropriate documentation was not verified by the Program prior to issuing the licensing 

actions. The 2014 IMPEP review team made the following recommendation.

 

2014 Recommendation: “The review team recommends that the State review all active medical 

licenses and verify that previously approved authorized physician users have the proper board 

certification or training requirements, and preceptor attestation, and develop and implement a 

process that will ensure proper verification and documentation of user qualifications for 10 CFR 

35.300 (KAR 28-35-264) uses of byproduct material.”

In response to the recommendation, immediately following the 2014 IMPEP review and prior to 

the Management Review Board meeting, the Section completed the review of all licenses that 

authorized 10 CFR 35.300 uses for authorized user board certifications, training requirements, 

and preceptor attestations. Licensees were contacted to review physician authorizations and 

verify training. Licenses that had been archived were returned to the Section so that previous 

authorized user documentation could be scanned and entered into the physician files in the 

database. All license writers were provided additional training on 10 CFR 35.300 uses and 

needed authorized user documentation.

The Section also participated in the NRC webinar training on medical inspections and licensing 

activities held on December 2, 2014.
Kansas Department of Health and Environment

Periodic Meeting Summary Page 5

The Section implemented additional modifications to the verification process to ensure it will 

include the proper documentation.

• The Section contacted each medical licensee to determine if any Authorized Users were 

performing procedures they were not qualified to perform. No concerns have been 

identified.

• The Section completed an audit of all active medical licenses.

• Changes to the database have been made to allow license reviewers to enter 

information about training and experience. When an attempt is made to authorize a user 

for a particular license, an error message will be received if the authorized user does not 

possess the appropriate qualifications and it will allow the license reviewer to update the 

missing information.

• The Section revised procedures to adopt a new license format. Licensing by restriction 

is the exception rather than the rule for medical licenses. Instead of authorizing a user 

for 35.300 except X, Y, and Z, they will be authorized for the uses referenced in 35.392, 

35.394, or 35.396, as appropriate. This change was incorporated into the database.

Technical Quality of Incidents and Allegations (2014 IMPEP: Satisfactory, but Needs 

Improvement)

The 2014 IMPEP review determined that the Section’s poor response to a significant well 

logging event where two well loggers received radiation exposures in excess of regulatory limits 

and the licensee’s handling of well logging sources created the potential for significant health 

and safety consequences to its workers and public resulted in the less than satisfactory rating 

for this indicator. No members of the public were exposed to radiation from this incident. The 

root causes of the Section’s poor performance was determined to be insufficient management 

oversight of this particular investigation and the Section’s procedures did not have specific 

guidance on when an onsite investigation should be conducted. The Section implemented 

procedural and management oversight changes to prevent recurrence.

Since the 2014 IMPEP review, 23 events were reported to the Section. Eight of the 23 events 

were reportable to the NRC Headquarters Operations Officer or to the Nuclear Material Events 

Database (NMED). All eight reportable events have been investigated and closed by the 

Section. One event had an outstanding request open from NMED and four events were 

reported to the NRC beyond the time period allowed by procedure. The Section Supervisor 

acknowledged that the NMED requested information was prepared but not transmitted. The 

Program Director acknowledged that the late reporting of incidents could have been due to the 

management transition within the Program.

Compatibility Requirements (2014 IMPEP: Satisfactory)

The Program maintains a database to track regulatory updates as they become available from 

the NRC. The responsibility for rulemaking was transferred from outside of the Section to the 

Section Supervisor. The supervisor provides timely assignments of new regulation 

amendments to the appropriate staff. The Kansas regulatory approval process can be lengthy 

taking upwards of one year to complete, therefore in some cases, it is necessary to add license 

conditions to ensure compatibility with the NRC’s program is maintained.

At the end of the 2014 IMPEP review, the Program had three outstanding regulation 

amendment packages with NRC comments still waiting resolution. The final regulations 
Kansas Department of Health and Environment

Periodic Meeting Summary Page 6

incorporating the changes were being reviewed by the Attorney General’s office at the time of 

the period review. The regulation package at the Attorney General’s office also includes the 

final 10 CFR Part 37 regulations, which incorporates 11 comments received from NRC on the 

proposed Part 37 regulations. In the interim, Kansas added a license condition to the affected 

licenses that requires compliance with 10 CFR Part 37 regulations by reference.

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

No changes since last IMPEP. There are currently no SS&D manufacturers in Kansas. The 

Program has not received any applications for a new SS&D certificate.

Information Exchange

Current State Initiatives

• Implementation of 10 CFR Part 37 requirements.

• Technologically-Enhanced Naturally Occurring Radioactive Material (TENORM) – The 

Program staff is working with the Bureau of Waste Management to develop regulations 

for the disposal of TENORM in permitted waste disposal facilities.

• Current RAM and X-Ray Training Events – The Program is initiating annual training 

programs for licensees, registrants, and the general public. The Program is testing the 

concept of replacing the biennial radiation control program conference with annual 

regional radiation control program meetings. The initial plan is to conduct three regional 

meetings in 2016 and three in 2017 at various locations throughout Kansas. The 

effectiveness of this outreach to the community will be assessed after the 2017 

meetings.

• Working Groups and IMPEP team support – The Program has several members on 

various NRC, OAS, and CRCPD working groups, and have also participated on several 

IMPEP review teams.

Current NRC Initiatives

The following NRC initiatives were discussed at the periodic meeting.

• Project AIM

• Re-baselining of NRC activities

• Management Changes

• Agreement State training

• New methods of training offered by NRC

• Agreement State participation on working groups

• Plans to revise IMC 2800

• Comments being solicited for the “Policy Statement for the Agreement State Program”

Emerging Technologies

None Identified
Kansas Department of Health and Environment

Periodic Meeting Summary Page 7

State’s Mechanism for Evaluating Performance

The Section uses peer audit reviews of licensing actions and final management review of 

inspections reports and licensing actions to ensure the quality of regulatory products. Computer 

tracking mechanisms and checklists are utilized to ensure elements of the program are 

completed as required. In addition, the Section performs peer and management 

accompaniments to assess the quality of inspections to ensure that licensed activities protect 

public health and safety, and are performed in accordance with the regulations, procedures, and 

license conditions.

CONCLUSIONS:

The Kansas Radiation Control Program is effectively managing its radioactive material licensing, 

inspection, and incident response activities. The Program does not have any overdue 

regulation amendments. NRC staff recommends that the next IMPEP review be conducted as 

scheduled in June 2018.