ML20154C052

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Package of Blank Draft Insp Repts Used for Medical, Industrial & Academic Institutions
ML20154C052
Person / Time
Issue date: 01/06/1986
From:
NRC
To:
Shared Package
ML20154C051 List:
References
FOIA-85-845 NUDOCS 8603040556
Download: ML20154C052 (45)
v • d • e


Text

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= 3 DRAFT Module No. 787108 REGION III NUCLEAR MATERIALS SAFETY SECTION MEDICAL INSPECTION REPORT i

Inspection Report No.

Licensee (Name and address)

Licensee

Contact:

Telephone No.

License No. Docket No.

~

Last Amendment No. Date of Amendment:

Category: Priority:

Date of Inspection:

Type of Inspection: ( ) Announced ( ) Unannounced ( ) Normal

( ) Initial ( ) Special ( ) Reinspection Next Inspection: ( ) Reduced (- ) Extended Program Codes: ( ) 02110 - Broad ( ) 02120 - Group ( ) 02121 - Non-Group-( ( ) 02210 - Eye App.

)302200 - Pv.Prac.

( )[02201

( ) 02220 - VAN ( ) 02500 - Pharmacy ( ) Other Summary of Findings and Action:

( ) No Noncompliance, Clear 591 issued. ( ) Action on Previous N/(l 8603040556 860106

) Noncompliance, 591 issued ( _) Regional Action PDR FOIA P041 SADIIH35-Eb45 ( ) Noncompliance, Appendix A ( ) Hg Ac~ tion Inspector (Signature) (Date Signed)

Approved (Signature) (Date Signed).

l I Rev. 08/01/84-

3

.. DRAFT i: Module No. 78710B a

1. INSPECTION HISTORY i

i

a. Item (s) of noncompliance or deviations noted during last inspection conducted on: ( ) Yes (. )No. Reponse letter dtd
b. Corrective Action Taken Status-1 Requirement Type of N/C ( ) Yes ( ) No Open Closed t

1 1

c. If any item (s) of noncompliance or deviations noted during last inspection were not corrected, explain:

i I

e 2. ORGANIZATION

a. Administrative structure meets License requirements: ( ) Yes ( ) No

! [L/C]

l I

i l

  • Attended Management close-out meeting i

d

2. Rev. 08/01/84

i.

. DRAFT Module No. 787102

.s

b. Use by authorized individuals: ( ) Yes ( ) No

[L/C].

c. Isotope Committee meets at required intervals: ( )Yes ( )No

[L/C]

d. Record of Committee meetinas: ( ) Yes ( ) No

[L/C]

4 a

3.

SUMMARY

OF PROGRAM 1

4. INTERNAL AUDITS OR INSPECTIONS
a. Required by License Condition: ( ) Yes ( ) No
b. Audits or Inspections conducted: ( )Yes ( ) No

[L/C) 4 1

3 Rev. 08/01/84

DRAFT Module No. 78710B

c. Records maintained: ( ) Yes ( ) No

[L/C]

5. TRAINING, RETRAINING AND INSTRUCTION TO WORKERS i

4

a. Training program required by License Condition: ( ) Yes ( ) No

. b. Training program implemented: ( ) Yes ( ) No

[L/C]

c. Retraining program required by License Condition: ( ) Yes ( ) No
d. Retraining program implemented: ( ) Yes ( ) No

[L/C]

e. Instruction to workers in accord with 10 CFR 19.12: ( ) Yes ( ) No

[19.12]

6. RADIOLOGICAL PROTECTION PROCEDURES

] a. Procedure referenced in License Condition: ( ) Yes ( -) No i

4 Rev. 08/01/84

DRAFT

+ Module No. 787108

b. Use in accordance with referenced procedure: ( ) Yes ( ) No

[L/C]

l-

! c. Individual's understanding of procedures adequate: ( ) Yes ( ) No

7. MATERIALS, FACILITIES AND INSTRUMENTS 1
a. Facilities as described in License Application: ( ) Yes ( ) No

[L/C]

b. Isotope, chemical form, quantity and use as authorized: ( ) Yes ( ) No

[L/C] A t

c. Tests required by License Condition or Regulations (1) Molybdenum-99 breakthrough: ( ) Yes ( ) No (2) Performed as required: ( ) Yes ( ) No

[L/Cand/or35.14(b)(4)iii]

?

1 (3) Leak tests: ( )Yes ( ) No

.. 5 Rev. 08/01/84

.-__-_______-___--_-_-_____-=- _: _ _ __ _ .__ - _ _ . _ _

n .

7.._.

I -

DRAFT' Module No. 787108 (4) Leak tests perfonned as required: ( ) Yes ( ) No

[L/C] [35.14(b)(5)(1)or35.14(e)(1)(1)]

T i

(5) Other tests required:

4

)

d. Inventory of sealed sources .

(1) Inventory of Group VI sources: ( ) Yes ( ) No

[35.14(b)(5)(v)]

i j

l (2) Inventory of calibration sources: '( ) Yes ( ) No l [35.14(f)(2)]

I I

l e. Storage of radioactive. materials l i

i -!

(1) Method used to prevent an unauthorized individual from entering a restricted area-is adequate: ( )Yes ( ) No l (2) Radioactive material secured to prevent unauthorized removal.from j an unrestricted area:- ( ) Yes ( ).No-  !

j [20.207]

i r

6 Rev. 08/01/84

DRAFT Module No. 78710B

f. Instrumentation (1) Operable survey instruments as described or equivalent to those described in License Application: ( ) Yes ( ) No

[L/C]

(2) Capability of radiation survey instruments adequate for program

( ) Yes ( )No (3) Calibration of survey instruments required: ( ) Yes ( ) No (4) Performed as required: ( ) Yes ( ) No

[L/C]

(5) Dose calibrator checks required: ( ) Yes ( ).No (6) Perfonned as required: ( ) Yes ( ) No

[L/C]

8. RECEIPT AND TRANSFER OF RADI0 ACTIVE MATERIAL
a. Survey of incoming packages: ( ) Yes ( -) No

[20.205(b)(1)orL/C]

7 Rev. 08/01/84

DRAFT Module No. 787108

b. Record of survey: ( ) Yes ( ) No

[20.401(b)]

c. Procedure for opening packages: ( ) Yes ( ) No

[20.205(d)]

d. BPM transferred in accordance with 10 CFR 30.41: ( ) Yes ( ) No

[30.41]

e. Records of receipt and transfer maintained: ( ) Yes ( ) No

[30.51] .

9. PERSONNEL RADIATION PROTECTION - EXTERNAL
a. Film or TLD badge supplier: Frequency:
b. Reports reviewed by: Frequency:
c. NRC inspector reviewed personnel monitoring records for period to 8 Rev. 08/01/84

DRAFT Module No. 78710B

d. NRC forms or equivalent (1) NRC-4: ( ) Yes ( ) No Complete: ( ) Yes ( ) No (2) NRC-5: ( ) Yes ( ) No Complete: ( )Yes ( ) No

[20.401(a)]

i

e. Maximum quarterly whole body exposure:
f. Maximum quarterly extremity exposure:

. g. Licensee has implemented the ALARA program: ( ) Yes ( ) No i

h. Radiation survey of unrestricted area: ( ) Yes ( )No

[20.201(b) to show compliance with 20.105(b)]

1. Record of survey maintained: ( ) Yes { l No

[20.401(b)]

4 l

j. Radiation survey of use areas (hot lab, therapy treatment area, patient's room, etc.): ( ) Yes ( ) No

[L/C]

4 I

, 9 Rev. 08/01/84

T DRAFT Module No. 78710B

k. Record of survey maintained: ( ) Yes ( ) No

[L/C]

10. PERSONNEL RADIATION PROTECTION - INTERNAL
a. Potential for exposure of individuals to airborne radioactive material exists: ( ) Yes ( ) No
b. Monitoring for airborne radioactivity conducted: ( ) Yes ( ) No

[20.201(b) to show compliance with all sections of 20.103 or L/C]

c. Records of monitoring maintained: ( ) Yes ( ) No

[20.401(b) or L/C]

11. RADI0 ACTIVE EFFLUENT AND WASTE DISPOSAL
a. Radioactivity in effluents to unrestricted areas: ( ) Yes ( ) No
b. Release in accordance with regulatory limits: ( ) Yes ( ) No

[20.106(a)]

10 Rev. 08/01/84

DRAFT Module No. 78710B

c. Solid waste disposal method:
d. Liquid waste disposal method:

l

e. Disposal of solid and liquid waste in accordance with regulatory l

l requirements (decay in storage): ( ) Yes ( ) No

f. Records of' disposal: ( ) Yes ( )No

[30.51]

g. Survey of waste prior to disposal: ( )Yes ( )No

[20.201(b) to show compliance with 20.301]

h. Records of surveys maintained: ( ) Yes ( ) No

[20.401(b)]

t i

i l . 11 Rev. 08/01/84 i

DRAFT Module No. 78710B

12. NOTIFICATIONS AND REPORTS
a. Licensee 'in compliance with 10 CFR 19.13 (Reports to individuals)

( )-Yes ( ) No [19.13]

t j

[ b. Licensee in compliance with 10 CFR 20.405 (Over exposures)

( ) Yes ( )No [20.405(a)]

1 1

4

c. Licenseeincompliancewith$0CFR20.403(Incidents)

( ) Yes ( )No [20.403]

I i

d. Licensee in compliance with 10 CFR 20.402 (Theft or loss) 4

( )Yes ( ) No [20.402(a)or20.402(b)]

t i

e. Licensee in compliance with 10 CFR 35.42 or 10 CFR 35.43 (Misadm.)

( .) Yes ( )No [35.42or35.43]

/

l l

7

~

l

i

~

12 Rev. 08/01/84

DRAFT Module No. 78710B

13. POSTING OF NOTICES Notices to workers posted: ( ) Yes ( ) No

[19.11(a) or (b) 19.11(c)]

14 CONFIRMATORY MEASUREMENTS

a. Independent measurements made by inspector: ( ) Yes ( ) No
b. Survey Instrument: .

NRC Ser. No.

Last date of calibration:

c. Describe type and results of measurements and compare with licensee's measurements:
15. POSTING AND LABELING Posting and labeling in accordance with 10 CFR 20.203: ( ) Yes ( )No

[20.203]

l 13 Rev. 08/01/84

DRAFT Module No. 78710B

16. LICENSE CONDITIONS
a. All License Conditions reviewed during inspection: ( ) Yes ( ) No
b. Activities were conducted in accordance with License Conditions except as noted elsewhere in this report: ( ) Yes ( ) No
17. BULLETINS AND CIRCULARS -
a. Bulletins and Circulars issued during current year:
b. Bulletins and Circulars received by licensee: ( ) Yes ( ) No
c. Licensee took appropriate action in response to Bulletins and Circulars: ( ) Yes ( ) No 14 Rev. 08/01/84

DRAFT Module No. 787108 4

18 TRANSPORTATION (10 CFR 71.5a and 49 CFR 171-178)

Yes- N/A Vio

a. License makes shipments of RAM? ( )~ () ()

i If no, check N/A and stop here: i.

j If yes, complete the following items:

l b. Such shipments consist of:

i ( ) Radwaste

( ) Sources / products *

[

( ) Other j c. For radwaste shipments are:

f ( ) by licensee, using comon carrier 1

j ( ) through Radwaste Broker name of broker i

i

{

d. Licensee-is aware of 10 CFR 61 () () () i Radwaste requirements for generators?  !

i l

! Licensee has classified and characterized i

his radwaste? (20.311(d)) () () ()  ;

i k

I 1

1 i  !

1

.I 15 Rev. 08/01/84

I DRAFT Module No. 787108

e. For shipments: l

() () ()

Licensee uses authorized packages 7 (173.415-16)

Package type used:

} .

2 .For D0T-7A, licensee has performance test records

  • 1 i

on file? (173.415(a)) () () ()

! For special fonn sources, licensee has per-

! fomance test records on file for each source '

i l'

design? (173.476(a)) () () () ,.

) ,

Packages are properly labeled? (172.403 & () () (- )

4 173.441)

Packages are properly marked? (172.300.172.301. () () ()

172.310 j Proper shipping papers are prepared for) 1 j each shipment? (172.200,172.201,172.202, () ( -) ()

i 172.203(d))

Notes / Comments

J J

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l 4

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l

16 Rev. 08/01/84

+

DRAFT Module No. 787108

19. CONTINUATION OF REPORT ITEMS f

i l

. 17 Rev 08/01/84

N .

( . . . . . . . . .

i

,i .

./

  • Module No. 787208

/ .

MEDICAL TELETHERAPY INSPECTION REPORT

= o

  • Inspection Report No. ,

Licensee (Name and Address) iicensee

Contact:

Telephone No.

License No. Docket No.

Last Amendment No. Date of Admendment:

Category: Priority:

Date of Inspection:

Type of Inspection: ( ) Announced ( ) Initial t-( ) L'nannounced ( ) Special i

l

( ) Reinspection l

Surrary of Tindings and Action:

! ( ) No Noncompliance, clear 591 issued ( ) Action on Previous N/C

( ) Noncompliance. 591 issued ( ) Regional Action I

( ) Noncompliance. Appendix A ( ) HQ Action Inspector:

(Signature) (Date Signed)

Appioved:

I (Signature) (Date Signed) l d.

l Revision: 10/81 I

i

i 2.' INSPECTION HISTORY I

a. Ites(s) of noncompliance or deviations noted during last .

inspection conducted on: ( ) Yes ( ) No.

Corrective Action Taken Status

b. Requirement Type of N/C ( ) Yes ( ) No Open Closed If any ite=(s) of nonco=pliance or deviations noted during last c.

.i inspection were not corrected, explain:

  • J
2. PERSONS CONTACTED i

l i

  • Attended Exit Interview 9

8.

. . . . . . . . . . . . . . _ . . . . . . . . . . . . . ~ . _ . . . . .

3

3. "

SUMMARY

OT PROGRAM . q Number of patients currently being treatedt

4. CRCANIZATION ,
s. Material used by or under supervision of authorized users:

( ) Yes ( ) No, 2

I

b. System to control dose to patient as specified by license condition. ( ) Yes ( ) No. -

[

c. System for rechecking dose calculations ( ) Yes ( ) No.
d. Name of consulting physicist if not listed in part 2. ( )N/A
5. TRAIN 1NC e, Individus1 designated as "gualified expert" has
a. l I

to

. . .'.....-.- --- - .- ~ .. .....-- - .. -.... - - . .

- . s

. Certification by:

or:

r Education and Experience () Yes

() No (10 CTR 35.24 (a) or (b) ) '

b. Record of " qualified expert's" t, raining available ( ) Yes ( ) No.

13 CFR 35.27 (c)

Training program for personnel implemented: ( ) Yes ( ) No c.

j

( ) N/A.

r t

d. Retraicing program implemented: ( ) Yes ( ) NJ ( ) N/A.

t

e. Instruction to workers in accord with 10 C11t 19.12 () Yes

() No. ,

t.

L- - - - - - _ _ _ _.__.__ _ - - --_----_____---- _--------___ ____.-_ _______ _ - - - _ .

S a

6. RADIOLOGICAL PROTECTION PROCEDURES
s. Emergency Procedures posted ( ) Yes ( ) No.
b. Individuals understanding of operating and emergency procedures adequate ( ) Yes ( ) No.
7. MATERIALS, FACILITIES AND INSTR 1.'MENTS
a. A=ount and use of material as authorized ( ) Yes ( ) No.
b. Possession and use of depleted uranium shielding as authorized

() Yes ( .) NO ( ) N/A

c. Facilities as described in License Application: ( ) Yes ( ) No  ;

- l s.

I

- e.

d.- Five year maintenance check performed: ( ) Yes ( ) No -( ) N/A. '

t 1

e. Performed by persons specifically authorized to do so: ( ) Yes

?

( ) No ( ) N/A l

> f. Tacility provided with system to permit continuous observation of the patient: ( ) Yes ( ) No

g. Facility provided with interlock system to control access to treatment room: ( ) Yes ( ) No
h. dnterlocksystemtestedat6-monthintervals: ( ) Yes ( ) No.

8.

t t

,c., - - , , - - - ., a-.-- ,----n-,_ . , . . , , , , . _ , - . - _ . . . . . _ _ _ . _ _ _ - - . - , , , e ,~-- .r- ,,v.-n- . , - - -.

~ - .

~

1. Records of interlock tests () Yes () No.
j. Leak tests performed as required () Yes () No
k. Leak test performed by authorized individual () Yes ( ) No j

i r

1. Results of leak tests recorded () Yes ( ) No -

I

! m. Po. sting of area, rooms and teletherapy unit is adequate l

() Yes () No

m. Tacility maintained locked except during periods when access to the area is required () Yes () No e.

4

. -S-s

. o. Survey instruments calibrated as required ( ) Yes ( ) No

p. Dosimetry system calibrated by NBS or accredited lab within I

two years ( ) Yes (,) N'o

. N[; ,

8. RECEIPT OT MATERIAL

'- * ' _\ ,. -

m

. a. Transfer of licensed hterial in accordance with Part 30 l and license conditions ( ) Yes (') go ( ) N/A t . .

/

b. Record of transfer and receipt maintained; (.) Yes ( ) No ( ) N/A

) s

  • +

s

9. PERSONNEL RADIATION PROTECTION - EXTERNAL. ,

, ,.a. Film or TLD badge suppliest. Frequency:

b. Reports reviewed by: _ Trequency:

. s s ., ,

c. NRCInspectorreviewedpersonnelmonitorid$recordsfor

~

period -. to _

r . -

  • . 6

, e 4

, - - - - _ --- m- - - - . y , _, , . - -_ _. _

m , . -

7.-- 3

- ~ ~

9_

e

d. NRC form or equivalent (1) NRC-4: ( ) Yes ( ) No Complete: ( ) Yes ( ) 1io (2) NRC-5: ( ) Yes ( ) No Complete: ( ) Yes' ( ) No
e. Nbximun quarterly whole body exposure:
f. Nbximum quarterly extremity exposure:
g. Licensee has implemented the AL' ARA Program ( ) Yes ( ) No
10. SURVEYS
a. Surveys have been conducted of source head:
1. before first patient treatment ( ) Yes ( ) No
2. after new source installation ( ) Yes ( ) No ,

. b. Surveys of areas adjacent to treatment room were conducted: ,

l

1. before first treatment ( ) Yes ( ) No  !

I 1

2. af ter new source installation ( ) Yes ( ) No ( ) N/A
3. after any changes in: room shielding, location of the unit within the treatment room or use of the unit

() Yes ( ) No () N/A

/

i

?>

r s

.c . Reports of above surveys have been submitted to the commission -

( ) Yes ( ) No

. x

11. NOTIFICATIONS AND REPORTS
a. Licensee in compliance with 10 CFR 19.13 (Reports to individuals)

( ) Yes ( ) No . , ,

b. Licensee in compliance with 10 CFR 20.405 (over exposures) 1

( ) Yes ( ) No

c. Licensee in compliance with 10 CFR 20.403 (Incidents)

() Yes ( ) No

, s .

d. - Licensee in compliance with 10 CTR 35.42 or 10 CTR 35.43 (Misadministration) ( ) Yes - ( ) No 1

1 8-

12. POSTING OF NOTICES Notices to workers posted: ( ) Yes ( ) No N

s .

g 13. BULLETINS AND CIRCULARS

a. Bulletins and Circulars issued during current year: ,

~ .

b. Bulletins and Circulars received by licensee: ( ) Yes ( ) No

~

c. 2.icensee took eppropriate action in response to Bulletins and Circulars: ( ) Yes ( ) No
14. TELETHEPA?Y CALIBRATION A. Tull Calibration
1. Perfomed:
a. prior to first use on hurans ( ) Yes ( ) No b.

after-changes in equipment ( ) Yes ( ) No

c. annually ( ) Yes ( ) No

. 2. Full Calibration Includes

s. accuracy + 3% ( ) Yes ( ) No n.

., en . - -- , -e , - - ,- ----,

1 s

b. Congruence ( ) Yes ( ) No

. 1

- l l

c. Uniformity of beam ( ) Yes ( ) No

. d. For all field sizes and treatment distances ( ) Yes ( ) No

3. Proper procedure followed'- JUGH ( ) Yes ( ) No
4. Performed with NBS calibrated instrument ( ) Yes ( ) No
5. Records of full calibration ( ) Yes ( ) No B. Monthly Spot Checks
1. Performed monthly ( ) Yes ( ) No
2. Performed by or in accordance with procedures established by qualified expert ( ) Yes ( ) No
3. Spot Checks Includes
a. Yimer accuracy () Yes ( ) No ,,

's 4

b. Congruence ( ) Yes ( ) No , ,

. c. Accuracy of distance measuring device ( ) Yes ( ) No

d. Output ( ) Yes . ( ) No
e. Difference between measured and expected output

() Yes () No

~

i

f. Spot checks performed using NBS/ regional lab calibrated instrument or direct intercomparison with same 1 () Yes () No i -

1 .

3 Records of monthly spot check ( ) Yes ( ) No l

15. PROTOCOL i 1. Does licensee participate?

( ) Yes - Complete Section 17 only i

( ) No - Completa Sections 16 and 17

2. If yes, protocol is part of:

".' ( ) NBS )

- ( ) Nations 1 Cancer Institute Center for Radiological Physics

( ) AAEH - Radiological Physics Center 8.

l

3. Date of last intercomparisons e'

. . _ _ _ _ - . . - _ _ _ _ _ - , . _ . . . . . _ _ _ y, _ . ~ ~... -~ ._,,.

4

( ) Yes ( ) No

4. Were results within + 5%

9

16. OUTPUT VERIFICATION - .

A. Type of Unit

~ _ Curies as of co-60
Cs-137: (date)

.Model:_

Machine make:

Shutter Type:

_ Isocentric Type of machine mount: Vertical i

f Other (Specify):

B. Licensee's Data Takt , Fi:N ( ) Monthly Spot check

( ) P'ull Calibration 1

Valid for:

. . rad roentgen / sin

' D or X =

CM SSD SAD at I

using:

i

( ) no phantom (R in air) 1 ( ) muscle miniphantom

( ) water miniphantom

( ) muscle large phantom

- ( ) water large phantom 1

- Factors used by' licensees

- ( ) roent$en to rad conversion (f)

~

f muscle .957 i

f water = .965, 1

l l

1

. - . , ._._- -_,. - _ - _- --- , - . _ - . - _ . ~ _ . , - _ - . - . . . . . . . . . . . - . _ _ _ . . . - .-..

l- . . -. ~ .-... . . . . . . . . . . _ _ . . .

s

- 4

- ( ) attenuation (Aeg)

.985 .

. ( ) Inverse Square (SSD) = .9876 where SSD = 80.0 cm .

( ) Backscatter Factor (BSF) 1.036 for 10 x 10 cm field

( ) Tissue / Air Ratio (TAR) .

( ) Percent Depth Dose

()CA

( ) Others C. NRC Calculations

1. Instru=ent used:

, ( ) Victoreen R meter: Serial No. Chamber No.

( ) Victoreen Electrometer: Serial No.

Chamber No.

Chamber Calibration Factor (Nc) =

2. Physical Factora  ;

C Temperature (Tc) l aun Hg (uncorrected)

Pressure (P) s.

. 760 C = 3D

F

=

j T-P 29 5 I

f>

t t

3. Timer Error Long exposure: Time (t )

y

. Reading (Mg )

Short exposure: Number of exposures (n)

Total i.ime (t2 )

Reading (H2 )

Calculation of timer error:

g ae Mt21 -Mti2 a Mni -M2

.i

4. Calculation of Output i

D or X =. M' -

(Nc)(C7 ,y) t t- % .

5. Unit conversion X= R/ min = C/kg/ min (100 1 - 2.58 x 10-2 C/kg) '

D= rad / min = Gray (Gy/ min)

( 1 Cy = 100 rad)

6. Percent Error Licensee - NRC ,

Licensee 17.',' OTHER TESTS

, 1. Congruence of light and radiation

2. Accuracy of distance measuring light, J

s "

17

(

3. Door and console safety interlocks operable: ( ) Yes ( ) No

. 4. Warning lights and area monitors operables ( ) Yes ( ) No

5. Nead survey i 1 N / .

N

/

' / --~

NJ

' /,\ I

/ P g I s l /

1 .

(2 mR/hr average 42 mR/hr average

,or 10 mR/hr maximum or 10 mR/hr maximum

! at 1 meter at 1 meter

( ) Yes ( ) No ( ) Yes ( ) No

6. Area Survey:

Survey results of console area and entrance to treatment room with beam "on".

O

e. l l

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l 8

s Modula N3. 87100 REGION III NUCLEAR MATERIALS SAFETY.SECTION

. INDUSTRIAL - ACADEMIC INSPECTION REPORT Inspection Report No.

Licensee (Name and Address)

Licensee

Contact:

Telephone No.

L.icense No. Docket No.

Last Amendment No. Date of Amendment:

Category: Priority:

Program Code:

Date of Inspection:

Type of Inspection: ( ) Announced Initial

( ) Unannounced Special Reinspection Next Inspection ( ) Normal () Reduced ( ) Extended Summary of Findings and Action:

( ) No Noncompliance, Clear 591 issued ( ) Action on Previous N/C

( ) Noacompliance, 591 issued ( ) Regional Action

( ) Noncompliance, Appendix A ( ) HQ Action Inspector:

(Signature) (Date Signed) l Approved:

(Signature) (Date Signed)

Revision 8/1/84 y' 2)"

)

- . = .

Module No. 87100 INDUSTRIAL - ACADEMIC IN!PECTION REPORT Licensee: Lic. No. Amendment No.

Date of Inspection:

1. INSPECTION HISTORY
a. Items of noncompliance or safety items noted during last inspection conducted on Yes No Corrected by letted dated
b. Requirement Corrected Not Corrected
c. If any items of noncompliance or safety items noted during the last inspection were not corrected, explain:
2. Organization
a. Organizational structure as described in application or letter Dated , Or
b. List primary licensee contact: Telephone No.
c. Comments:
3.

SUMMARY

OF LICENSED PROGRAM (Kind of program, number of people, rate of use or quantities on hand, places and frequency of use, type, quantity and useasauthorized).

2 Revision 8/1/84

Module No. 87100

4. INTERNAL AUDITS OR INSPECTIONS
a. Required by L/C or application: Yes No If "Yes":
1) By whom
2) Frequency Announced: Unannounced:
3) Scope
4) Records maintained: Yes No
5) Records reviewed: Yes No
6) Period Reviewed:
b. Comments (responsibility of auditor or committee, management control):

i 1

5. - TRAINING, RETRAINING, AND INSTRUCTIONS TO WORKERS
a. Training program specified in L/C or application: Yes No
b. If training program is required, describe scope of program:
c. Retraining required: Yes No If "Yes" is retraining: Complete Incomplete 1 Are tests and/or examinations required: Yes No 2 If "Yes" are records available: Yes No
3 Reviewed test results: Yes No 4 Period reviewed:
5) Comments (per cent completed, test results, etc.):

-f

d. Training provided, but not covered above:

4

e. Instructions to workers in accord with 10 CFR 19.12: Yes No 3 Revision 8/1/84

Module No. 87100 L 6. RADIOLOGICAL PROTECTION PROCEDURES

a. Doerating and Emergency Procedures I 1 Required by L/C or application: Yes No 2 Provided, but not required by L/C or application: Yes No

, 3 Procedures reviewed: Yes .No i 4 Appeared adequate: Yes No i 5 Comments (personnel's understanding of procedures):  :

i

b. Changes in procedures since last inspection: Yes No
1) Were changes authorized: Yes No ,

j 2) Comments-

  • 1 I

J s

7. INSTRUMENTATION
a. Type (s) of radiation survey instruments on hand as per L/C, applica-tion or equivalent: Yes No
1) If "No" list changes:

I l

b. Capability of radiation survey instruments adequate for program:

Yes No

c. Calibration of instruments required: Yes No
d. If "Yes", instruments calibrated in accord with requirements:

I Yes No 1

4

e. Comments:

1 1

I

! l i

4 Revision 8/1/84

, Modulo No. 87100 l

8. MATERIALS
a. Radioactive material secured to prevent unauthorized removal from:  !
1) Restricted area: Yes No
2) Unrestricted area (20.207): Yes i b. Method of control appear adequate: Yes No I
c. Comments:

4 I

I 9. FACILITIES 4

q . a. Facilities described in letter or appplication: Yes No

b. Facilities inspected
Yes No
c. Comments:

I i

10. POSTING AND LABELING
a. Posting and labeling in accord with 10 CFR 20.203
Yes No
b. Comments ,

4 j

I I 11. RECEIPT AND TRANSFER OF MATERIAL i

a. Proceduresforpickingupandreceivingpackages(10CFR20.205[b][c]):

. Yes No l

1) Incoming shipments monitored: Yes No
2) Records of monitoring maintained (10 CFR 20.401Lb]): Yes No i 3 Records reviewed by NRC inspector: Yes No 4 Period reviewed:
b. Procedures for opening packages (10 CFR 20.205[d]): Yes No
c. Comments:

1 4

j 5 Revision 8/1/84 l

Module N3. 87100 3 d. Records of receipt and transfer of material available (30.51[a];

40.61[a];70.51[b][1]): Yes No 1 If "Yes", review of records was made by inspector: Yes No 2 Period reviewed:

i 3 Comments:

)

i

e. Packages on hand meet labeling requirements (49 CFR 173.399):

Yes No

} Comments:

i i

l f. Reports to commission required by L/C or regulation submitted:

Yes No

. Comments:

1 4

l 12. PERSONNEL RADIATION PROTECTION - EXTERNAL

a. Film or TLD badge supplier i
b. Badge exchange frequency
c. Reports reviewed by 1
1. d. Records reviewed for period to by NRC inspector
e. NRC forms or equivalent
1) Yes No Complete: Yes No

, 2) NRC-4(20.102'b[)):

NRC-5 (20.401,a., : Yes

. No Complete: Yes No Maximum whole body quarterly exposure:

Maximum extremity quarterly exposure i 3) Comments:

f. Pocket dosimeters used: Yes No i 1 Type used:

2 Frequency of recharging:

3 Frequency of reading:

4 Comments:

l i

g. Direct radiation surveys of restricted and/or unrestricted areas being made: Yes No 1 Records of surveys being maintained: Yes No 2 Records of surveys reviewed: Yes No l 3 Period reviewed: l 4 4 Comments:

1

. l 4

. 6 Revision 8/1/84 i

Module No.87100 l

! 13. PERSONNEL RADIATION PROTECTION - INTERNAL i a. Potential for exposure of individuals to airborne radioactive mate-rial exists: Yes No

1) If "Yes" does program for monitoring and control exist:
  • i Yes No j 2) Program for monitoring and control appears adequate:

Yes No l b. Comments: l t

i i c. Respiratory protection program required by L/C or application:

4 Yes No <

j 1) If "Yes" were respiratory protection procedures reviewed:

, Yes No

2) Respiratory protection procedures appear adequate

Yes No j 3) Comments:

i i,

I d. Bioassay program required: Yes No 1 If "Yes" was bioassay program reviewed: Yes No

! 2 Bioassay program appears adequate: Yes No i 3 Comments:

1 I

e. Smears and air samples:
1) Monitoring for airborne radioactivity is conducted (20.103):

Yes No

a. Records of monitoring reviewed: Yes No
b. Period reviewed:

i c. Records of monitoring appears adequate: Yes No S

2) Smear surveys being conducted (20.201.b): Yes No 4 a. Records of smear surveys reviewed: Yes No ,
b. Period reviewed:
c. Records appeared adequate: Yes No
3) Comments:

i l 14. LEAK TESTS

a. Leak tests required: Yes No
b. If "Yes" leak tests conducted: Yes No

! c. Records of leak tests maintained: Yes No

! d. Leak tests records reviewed: Yes No 7 Revision 8/1/84

Module No. 87100

e. Period reviewed:
f. Records of leak tests appear adequate: Yes No
g. Comments:
15. RADI0 ACTIVE EFFLUENT CONTROL AND WASTE DISPOSAL -
a. Byproduct material released to atmosphere and/or sewer (20.106 and 20.303):

Yes No

b. Records of releases or radioactive effluents maintained (20.401):

Yes No

1) Period reviewed:
2) Records appear adequate: Yes No

. c. Solid waste disposal method:

1 Records of disposal maintained (30.51): Yes No i

2 Surveys of waste prior to disposal made (20.201): Yes No l

3 Period reviewed:

4 Records of surveys appear adequate (20.401): Yes No

d. Comments:

l t

l l

i l

l i

8 Revision 8/1/84 l

\_____________-__________ _ _ _ . _ _ _--- _- _ - - _ _ _ _ _ - _ _ _ _ - _ _ _ -

Modulo No. 87100 INDUSTRIAL / ACADEMIC

16. TRANSPORTATION (10 CFR 71.5a and 49 CFR 171-178) Yes N/A Vio
a. Licensee makes shipments of RAM 7 ( )( )( )

Such shipments are:

( ) delivered to common carriers?

( ) transported in licensee's own vehicle as private carrier?

( )both?

If above is yes, complete items below;

b. Areauthorizedpackagesused?[173.415-416] ( )( )( )

Package types used:

( ) 00T-7A Type A [173.415(a) performance test records on file? ( )( )( )

( ) DOT-55[173.416(a)]

licensee aware of 6/30/85 cutoff on use? ( )( )( )

( Excepted, Instruments / articles [173.421-424]

! ( LSA-strongtight[173.425(b)(1)]

(

NRC-Certified NRCC0C'sonfile?[71.12(c ]173.416(b)] )(1)] ( '( )( )

l RegisteredwithNRCasuser?[71.12(c)(3)

Documented NRC-Approved Q/A Program? [71.17(b)]

(

( )(

h( )(

)(

)

)

l NRC Q/A Approval No.:

( ) Other:

c. Special Form Material performance test records available foreachsourcedesign?[173.476(a)]

( )( )( )

i d. Packages Labeled as required? [172.403(a)]

) Excepted ( )WI ( )Yll

( )( )( )

l ( ( )Yll!

Surveys performed to select correct label category and compliance with. Rad. Limits? [173.475(1)]

( )( )( )

l

e. Packages Marked as required, i.e., proper shipping name, 10 No., Spec. No., C0C Ho., etc. [172.300]

l f. ( )( )( )

l Shipping Such papers papers prepared contain requiredfor each shipment?

information? [172.203(d (172.200])]

( )( )( )

i

g. For Licensee private carrier shi ments:

Vehicles placarded as required? l172.500,172.504 Table 1) ( )

l Cargo blocked, braced, tied down in vehicle? [177.842(d)] l AnyincidentsreportedtoDOT?[171.15-16] )j

h. Does Licensee ship any radwaste?

If es, are shipments:

)( )(

i 1

( tendered to common carriers by licensee? ( )

l ( tendered through a Radwaste Broker?

If yes, name of Broker

( )( )( )

is licensee aware of 10 CFR 61 waste generator requirements? [10CFR61]

( )( )( )

Has licensee classified and characterized waste? ( )( )( )

[20.311(d)]

9 Revision 8/1/84

4 i.

Modulo No. 87100

17. NOTIFICATIONS AND REPORTS
a. Licensee in compliance with 10 CFR 19.13 (reports to individuals):

Yes No

]

b. Licensee in compliance with 10 CFR 20.405 (over exposure):

Yes No

{ c. Licensee in compliance with 10 CFR 20.403 (incidents):

Yes No i

d. Licensee in compliance with 10 CFR 20.402 (theft or loss):

j Yes No

e. Comments i -

1 1

i 1

j 18. POSTING 0F NOTICES l a. Licensee in compliance with 10 CFR 19.11(a) or (b): Yes No l b. Licensee in compliance with 10 CFR 19.11(c): Yes No

c. Comments:

i

) 19. ENVIR0f4 MENTAL MONITORING PROGRAM i

i a. Environmental Monitoring Program required: Yes No i

b. If "Yes" records reviewed: Yes No j
c. Period reviewed: >
d. Records appeared adequate: Yes No

]i e. If Environmental Program is not required, briefly describe any existing program: t

. i i  !

t

! 10 Revision 8/1/84 i I

Modulo No. 82100

20. CONFIRMATORY MEASUREMENTS
a. Independent measurements made by inspector: Yes No
b. Comments (describe type, results, comparison with licensee results):
21. INDEPENDENT INSPECTION EFFORT
a. Coment on type of independent inspection effort conducted:
22. CONTINUATION FROM PREVIOUS PARAGRAPHS - USE BACK OF PAGE IF NECESSARY 11 Revision 8/1/84
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