ML24047A296

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Appendix 4.7-1 RCP-904.1 Management of Allegations (CR) 11/09/2023
ML24047A296
Person / Time
Issue date: 11/09/2023
From: Huda Akhavannik
NRC/NMSS/DMSST
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RCP-904.1 Rev 0 2/8/2024 Page 1 of 27 RCP-904.1 Rev 0 2/8/2024 Page 1 of 27 State of Connecticut Department of Energy and Environmental Protection Radioactive Materials Program RCP-904.1 Management of Allegations Prepared By: Kristina Verderame Date:

Reviewed By:

Date:

Approved By:

Date:

RCP-904.1 Rev 0 2/8/2024 Page 2 of 27 RCP-904.1 Rev 0 2/8/2024 Page 2 of 27 Revision Date Description of Changes

RCP-904.1 Rev 0 2/8/2024 Page 3 of 27 RCP-904.1 Rev 0 2/8/2024 Page 3 of 27 TABLE OF CONTENTS SECTION TITLE PAGE 1.0 PURPOSE..

4 2.0 SCOPE 4

3.0 REFERENCES

4 4.0 DEFINITIONS AND ABBREVIATIONS.

4 5.0 GENERAL..

5.1 Responsibilities.

5.2 Records..

5.3 Prerequisites..

6 6

9 9

6.0 PROCEDURE 6.1 Initial Contact 6.2 Disclosure of Alleger's Identity.

6.3 Controlling Allegations..

6.4 Referral of Allegations to Licensee 6.5 Investigations.

6.6 Close Out 6.7 Coordinating with Other Agencies.

ATTACHMENTS ATTACHMENT 1 Initial Contact Log.

ATTACHMENT 2 Nondisclosure Statement ATTACHMENT 3 Allegation Screening Form.

ATTACHMENT 4 Confidential Information and Files.

ATTACHMENT 5 Acknowledgement Letter to Alleger 9

9 11 13 15 18 19 20 22 24 25 26 27

RCP-904.1 Rev 0 2/8/2024 Page 4 of 27 RCP-904.1 Rev 0 2/8/2024 Page 4 of 27 1.0 PURPOSE This procedure is to ensure that any allegation made against a licensee is properly addressed and to provide guidance to protect the identity of the alleger. Actions taken in response to an allegation include investigation, documentation, and enforcement, as appropriate.

2.0 SCOPE This procedure applies to allegations associated with Connecticut Department of Energy and Environmental Protection regulated activities involving radioactive materials.

3.0 REFERENCES

3.1 Sections 22a-148 through 22a-165(h) of Chapter 446a - Radiation and Radioactive Materials of the Connecticut General Statutes 3.2 Sections 22a-153-1 to 22a-153-150, inclusive, of the Regulations of Connecticut State Agencies 3.3 Sections 1-200 through 1-259 of Chapter 14 - Connecticut Freedom of Information Act of the Connecticut General Statutes 3.4 Section 53a of Chapter 950 - Connecticut Penal Code 3.5 Section 6b of Chapter 439 - Department of Energy and Environmental Protection.

3.6 NRC Management Directive 8.8, "Management of Allegations."

3.7 NRC Inspection Manual Chapter 2800 Materials Inspection Program.

3.8 NRC SA-300, Reporting Material Events.

4.0 DEFINITIONS AND ABBREVIATIONS

4.1 Allegation

A declaration, statement, or assertion of impropriety or inadequacy associated with RMP regulated activities, the validity of which has not been established. This term includes all concerns identified by individuals or organizations regarding activities at a licensee's or applicant's facility. Excluded from this definition are inadequacies provided to RMP staff members by a licensee's management acting in their official capacity. Allegations regarding suspected improper conduct by an RMP employee do not fall within the scope of this procedure and shall be promptly reported to the employees immediate supervisor.

4.2 Allegation File: A secure hardcopy or electronic file that contains the documentation concerning the allegation, accessible by RMP staff and secured by the RMP.

4.3 Alleger

An individual or organization that makes an allegation. The alleger may be known or wish to remain anonymous.

RCP-904.1 Rev 0 2/8/2024 Page 5 of 27 RCP-904.1 Rev 0 2/8/2024 Page 5 of 27

4.4 Confidentiality

The protection of the allegers identity. Every effort will be made to protect information that could directly or otherwise identify an individual by name or the fact that a confidential source provided such information to the RMP (see attachment 4). Electronic communications may not be secure for confidentiality purposes.

4.5 Confidential Source: An individual who requests and, to the extent possible, is granted confidentiality by FOIA exemptions listed under CGS Section 1-210 or an individual that requests to remain anonymous for which personal information is not documented.

4.6 Investigation

For purposes of this procedure, an activity conducted by the program used to gather information related to the allegation by seeking confirmation to substantiate, evaluate and resolve an allegation.

4.7 Overriding Safety Issue: An issue that may represent an actual or potential immediate and/or significant threat to public health, safety, environment, or security, warranting immediate action by the licensee or RMP to evaluate and/or address the issue.

4.8 Personal Identifying Information (PII): means information that identifies an individual and includes an individual's photograph or computerized image, Social Security number, operator's [drivers] license number, name, address other than the zip code, telephone number, electronic mail address, or medical or disability information (CGS 14-10 (a) (3)).

4.9 Requirement

A legally binding obligation such as a statute, regulation, license condition, or order.

4.10 Secure Files: Allegation Files are secured when not in use and access is controlled and limited to RMP staff who are actively using the particular case file because they are required to address the allegation.

4.11 Intentionally: A person as defined in statute acts intentionally with respect to a result or to conduct described by a statute defining an offense when his conscious objective is to cause such result or to engage in such conduct (CGS 53a-3(11)).

4.12 Criminal Negligence: A person as defined in statute acts with criminal negligence with respect to a result or to a circumstance described by a statute defining an offense when he fails to perceive a substantial and unjustifiable risk that such result will occur or that such circumstance exists. The risk must be of

RCP-904.1 Rev 0 2/8/2024 Page 6 of 27 RCP-904.1 Rev 0 2/8/2024 Page 6 of 27 such nature and degree that the failure to perceive it constitutes a gross deviation from the standard of care that a reasonable person would observe in the situation (CGS 53a-3(14)).

4.13 Knowingly: A person as defined in statute acts knowingly with respect to conduct or to a circumstance described by a statute defining an offense when he is aware that his conduct is of such nature or that such circumstance exists. (CGS 53a-3-(12)).

4.14 Careless Disregard: means a situation in which a person acts with reckless indifference to at least one of three things: (1) the existence of a requirement, (2) the meaning of a requirement, or (3) the applicability of a requirement. Careless disregard occurs when a person is unsure of the existence of a requirement, the meaning of a requirement or the applicability of a requirement to a situation, but the person engages in conduct that the person knows may cause a violation, without first ascertaining whether a violation would occur (CGS 22a-6b).

4.15 FOIA - Freedom of Information Act 4.16 LI - lead Investigator 4.17 NMED - Nuclear Materials Event Database 4.18 NRC - Nuclear Regulatory Commission 4.19 RCPD - Radiation Control Program Director 4.20 SRCP - Supervising Radiation Control Physicist 4.21 RMP - Radioactive Materials Program 5.0 GENERAL 5.1 Responsibilities 5.1.1 Radioactive Materials Program (RMP) Staff 5.1.1.1 Any RMP staff member may receive or recognize an allegation while in the field.

5.1.1.2 Allegations may be communicated to the Department in person, by telephone, by e-mail or in print.

RCP-904.1 Rev 0 2/8/2024 Page 7 of 27 RCP-904.1 Rev 0 2/8/2024 Page 7 of 27 5.1.1.3 An allegation also may be recognized by an RMP staff member in information provided in a public forum such as television, radio, newspaper, internet, or social media.

5.1.1.4 RMP staff will be professional, and responsive to the alleger and are responsible for recording the initial allegation utilizing, documenting any contact information provided, and immediately referring the allegation to the Supervising Radiation Control Physicist (SRCP). RMP staff should inform the alleger of the option to remain anonymous prior to formally documenting any personal identifying information (PII).

5.1.1.5 The RMP staff member is also responsible for maintaining confidentiality of the allegers PII and all other confidential information prior to referral to the RCPD or designee.

5.1.1.6 This information must be documented in attachments 1 to 5, and the attachments filed, both electronically and in an Allegation File created specifically for each allegation. Access to allegation files is restricted to RMP staff or other designated staff when evaluating the specific allegation.

5.1.2 Lead Investigator 5.1.2.1 A member of the RCP may be designated as the Lead Investigator (LI). The LI coordinates with the SRCP and Radiation Control Program Director (RCPD) or designee for the processing and disposition of an allegation. Throughout the investigation, the LI is required to respond in a timely manner commensurate with the seriousness of the allegation and in consultation with the SRCP and RCPD or designee. The response to the allegation will be determined using Attachments 1 and 3 to determine the impact and required response.

5.1.2.2 The LI prepares all records and reports concerning the allegation. Initial Allegation Contact Log must be filled out in entirety, along with Attachment 3 Allegation Screening Form.

These records and reports will be used if the allegation is required to be reported to the NRC and through the Nuclear Materials Event Database (NMED). The LI is responsible for maintaining confidentiality of the allegers PII and any other

RCP-904.1 Rev 0 2/8/2024 Page 8 of 27 RCP-904.1 Rev 0 2/8/2024 Page 8 of 27 information deemed confidential and must discuss and provide a copy of Attachment 4 Acknowledgement Letter to Alleger.

5.1.2.3 Not all allegations will require immediate response. The LI must use Attachment 1 Initial Contact Log to determine if the reported allegation requires immediate attention. The LI, in consultation with the SRCP and RCPD or designee, will determine the required response to the allegation. All allegations should be addressed by the RMP within 90 days of initial contact or sooner in accordance with section 6.3. It may take additional time to investigate and close each case.

5.1.3 Supervising Radiation Control Physicist (SRCP) 5.1.3.1 Manages the response to allegations and maintains a filing system to track, resolve, and conduct periodic reviews of the allegations for their resolution/disposition (Allegation File).

5.1.3.2 Informs the RCPD or designee of the status of the investigation and recommends appropriate actions in response to allegations.

5.1.3.3 Instructs RMP staff on requirements of confidentiality and informs RMP staff who received original information and the Lead Investigator of their responsibility to protect the confidentially of the alleger and all other confidential information within the allegation.

5.1.3.4 Upon being informed of an incident through an inspection or investigation of the allegation, the SRCP will respond in accordance with RCP 904.2 Incident Response.

5.1.4 Radiation Control Program Director (RCPD) 5.1.4.1 Reviews and approves recommendations made by the SRCP before actions are taken in response to allegations.

5.1.4.2 Authorizes the release of the identities of allegers or confidential sources as provided in section 6.2. of this procedure after consultation with legal counsel.

5.1.4.3 Requests legal assistance from the Office of Legal Counsel, if required.

RCP-904.1 Rev 0 2/8/2024 Page 9 of 27 RCP-904.1 Rev 0 2/8/2024 Page 9 of 27 5.1.4.4 Refers allegations to the Nuclear Regulatory Commission or another Agreement State Radiation Control Program, if applicable.

5.1.4.5 Document any required procedural deviations.

5.2 Records 5.2.1 All allegation-related documentation is to be maintained in a secured Allegation File in the Radioactive Materials Program (RMP).

5.2.2 Allegation Files are secured when not in use and access is controlled and limited to RMP staff who are actively using the particular case file.

Electronic Allegation Files shall be limited to RMP staff required to address the allegation who have authorized access to the secured spaces.

5.3 Prerequisites To be assigned as lead investigator, the investigator should be fully qualified as an inspector of the modality being investigated.

6.0 PROCEDURE 6.1 Initial Contact 6.1.1 Evaluation is accomplished by technical review of the allegation, inspection, and information requested from the affected licensee, the individual informer, another Agreement State, or the NRC. As much information as possible is obtained and recorded from the alleger on the Initial Contact Log, (Attachment 1). If the notification is forwarded or received from the NRC, another state, or a local agency, use the same form and record all the information from the agency, individual, or organization contact. Note on the form the contacts information in case questions arise. For e-mail, fax, regular mail, or any form of communication that may contain the allegers identity, RMP staff must ensure that the identity is protected as indicated in section 6.2 of this procedure.

6.1.2 If the allegation involves discrimination on the basis of age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed,

RCP-904.1 Rev 0 2/8/2024 Page 10 of 27 RCP-904.1 Rev 0 2/8/2024 Page 10 of 27 sex, gender identity or expression, sexual orientation, and status as a veteran, refer the alleger to the State of Connecticut Commission on Human Rights and Opportunities, (860) 541-3400.

6.1.3 If the allegation requires criminal investigatory capacity, notify and request assistance from the Local Law Enforcement Agency (LLEA),

DEEP Environmental Compliance, and/or the Connecticut State Police/CT-DEEP Encon, and/or other federal agency such as the NRC and FBI, as appropriate. Examples that may require criminal investigatory capacity include but are not limited to an actual or attempted theft or threatened hijacking of a shipment or device containing radioactive materials, or an incident involving radioactive materials that are subject to 10 CFR 37.57 reporting requirements.

6.1.4 If the allegation involves a healthcare provider, contact the Connecticut Department of Public Health.

6.1.5 If the alleger refuses to provide his/her name or other form of identification, then obtain as much information as possible and advise the alleger that he/she may contact the SRCP in 30 working days for information regarding the response to the allegation.

6.1.6 Address the issue of confidentiality with the alleger in accordance with section 6.2 of this procedure.

6.1.7 Inform the SRCP of the allegation and submit completed Attachment 3.

The alleger's identity, or information that could reveal that identity, should be imparted to staff on a need-to-know basis and should not be revealed to personnel outside the Department. All documentation pertaining to the allegation shall be securely stored. Electronic Allegation Files are secured in a file folder dedicated to Radioactive Materials Program allegations.

Hard copies, when not in use, are limited to the RMP staff in a locked secure file cabinet. See Attachment 4.

6.1.8 Allegations received will undergo an initial screening (see Attachment 1 &

3). Generally, action will not be taken to determine the validity of an allegation, nor will an allegation be discussed with licensees or other affected organizations, until after the allegation has been discussed with the SRCP, RCPD or designee, and the Department Office of Legal Counsel. If those parties determine that an allegation proves to be unsubstantiated (unconfirmed), the alleger will be notified of the findings

RCP-904.1 Rev 0 2/8/2024 Page 11 of 27 RCP-904.1 Rev 0 2/8/2024 Page 11 of 27 of the allegation disposition and the allegation management process will be terminated.

6.1.9 Allegations received by the RMP staff, are given a sequential number (e.g., CTA-24-001) and an Allegation File is created. Electronic documents are placed in files accessible only to RMP staff. Hardcopy records are scanned to electronic files where they will be secure.

6.1.10 Provide the initial notification to the alleger by phone and document with a letter (Attachment 5) to the alleger. Include in the notification that the Department will evaluate the licensee's activities and response, and that the alleger or confidential source will be informed of the final disposition of the allegation. In the event that an alleger wishes to remain anonymous, no communication will be sent. The alleger should be informed that they must contact the RCPD for the final disposition.

6.2 Disclosure of Alleger's Identity and Confidential Information 6.2.1 RMP will make all reasonable efforts to maintain as confidential any information provided by the alleger that meets the criteria below.

However, the RMP cannot guarantee confidentiality once the investigation is complete. Disclosure of an allegers identity may be made in accordance with this section. Staff will mark all information deemed confidential as such on both hard copy and electronic files. Prior to terminating initial contact with an alleger, inform the alleger of the degree to which their identity can be protected, including but not limited to the following:

6.2.1.1 Confidential information including that which would reveal that identity, will be shared with RMP staff on a need-to-know basis.

Confidential information that needs to be protected includes, but is not limited to the following:

  • Birthdate
  • Name
  • Date and place of birth
  • Social security number
  • Government-issued identification.
  • Address
  • Telephone number
  • Medicare card
  • Hospital medical record number
  • Passport
  • Mothers maiden name

RCP-904.1 Rev 0 2/8/2024 Page 12 of 27 RCP-904.1 Rev 0 2/8/2024 Page 12 of 27

  • Biometric records
  • Educational records
  • Financial records
  • Other personally identifiable information 6.2.1.2 All confidential information including information regarding the allegers identity will be stored in a secure file electronically and the hard copy file will be secured at all times and under the control of the RCPD or designee, in the same manner as Allegation Files.

6.2.1.3 Hard copy Allegation Files are stored in a secured location when not in use and access is controlled and limited to RMP staff who are actively using the particular case file. Electronic Allegation Files are limited to RMP staff required to address the allegation and authorized access to the electronically secured space.

6.2.1.4 Inspection reports and correspondence with licensees, other agreement states, federal agencies (including NRC), other organizations, or individuals will contain no confidential information or information that could lead to the identification of the alleger or confidential source.

6.2.1.5 The allegers identity and all confidential information regarding the allegers identity will not be disclosed outside of RMP, except under the conditions stipulated in this section.

6.2.2 Inform the alleger that disclosure of his or her identity or of confidential information may occur based on the criteria listed in Attachment 2 and that it may not be possible to determine the extent to which PII will be disclosed before completing the investigation or obtaining more information.

6.2.3 Obtain approval from the RCPD with consultation with the Office of Legal Counsel prior to any mandated disclosure.

6.2.4 Regardless of means by which an allegation is made, if the allegers identity is known, then inform the alleger by letter of the degree to which his or her identity may be protected as described in 6.2.1 through 6.2.3 using Attachment 5 Acknowledgement Letter to Alleger.

RCP-904.1 Rev 0 2/8/2024 Page 13 of 27 RCP-904.1 Rev 0 2/8/2024 Page 13 of 27 6.2.5 If the alleger wishes to remain anonymous but is providing information in confidence, inform the alleger that a non-disclosure statement (Attachment

2) is available and will be sent to them via certified mail.

6.3 Controlling Allegations 6.3.1 Allegations should be addressed according to the guidelines listed below:

6.3.1.1 Overriding safety issue - shall be addressed immediately; 6.3.1.2 High safety significance - should be addressed expeditiously, usually within 30 working days; or 6.3.1.3 Low safety significance - should be assessed internally within 30 days and addressed as priorities and resources permit, within 90 days of receipt.

6.3.2 Action by the SRCP.

6.3.2.1 Appoint a Lead Investigator for the allegation.

6.3.2.2 Ensure an Allegation File is opened for the allegation.

6.3.2.3 With the assistance of the Lead Investigator, perform an immediate assessment of the allegation in accordance with Attachment 3.1-3 to determine if an overriding safety issue exists.

6.3.2.4 An allegation is a declaration, statement, or assertion of impropriety or inadequacy associated with RMP regulated activities, the validity of which has not been established. This term includes all concerns identified by individuals or organizations regarding activities at a licensee's or applicant's facility or in the public domain. Examples of allegations are:

o Potential wrongdoing by a licensee, staff, or contractor; o A concern about a safety-conscious work environment problem at a facility; o Intentionally or knowingly falsifying records; o Bypassing safety interlocks.

If multiple allegations are made, as described above, the RCPD and SRCP must determine the priority of the allegations.

RCP-904.1 Rev 0 2/8/2024 Page 14 of 27 RCP-904.1 Rev 0 2/8/2024 Page 14 of 27 6.3.2.5 Any allegation determined to be an overriding safety issue will cause an immediate evaluation by the RMP. This evaluation may include the RCPD or designee, Radiation Duty Officer, a member of the Office of Legal Counsel, and other members of the RMP staff. All discussion with legal counsel concerning suspected wrongdoing shall be documented, stamped confidential, and filed within the Allegation File, if appropriate, the licensees folder.

6.3.2.6 As necessary, brief the RCPD or designee on the evaluation findings and recommendations.

6.3.2.7 Upon finding of an incident, immediately implement RCP 904.2 Incident Response.

6.3.3 Evaluation by Lead Investigator 6.3.3.1 In consultation with the SRCP, perform an immediate assessment of the allegation in accordance with Attachment 3 to determine if an overriding safety issue exists.

6.3.3.2 Determine, in conjunction with the SRCP, the actions necessary for resolution of the allegation including an investigation, enforcement actions (per RCP 902.1), etc.

6.3.3.3 Identify additional resources required for resolution of the allegation.

6.3.3.4 Develop a schedule for the resolution of each allegation consistent with the inspection schedule; unless the priority of the allegation causes immediate action.

6.3.3.5 With the approval of the SRCP, implement actions necessary for resolution of the allegation.

6.3.3.6 If an inspection is performed, focus should be placed not only on the particular allegation, but also on the overall area of concern, including safety culture. If the Lead Investigator receives notification of the finding of an incident, implement RCP 904.2 Incident Response and advise inspection staff of immediate actions taken to mitigate the incident and notify the SRCP.

RCP-904.1 Rev 0 2/8/2024 Page 15 of 27 RCP-904.1 Rev 0 2/8/2024 Page 15 of 27 6.4 Referral of Allegations to Licensees 6.4.1 The decision whether or not to refer an allegation to the licensee will be made upon the recommendation of the Lead Investigator with the approval of the SRCP and based on the considerations delineated in 6.4.2 and 6.4.3. If an allegation raises an overriding safety issue, the substance of the allegation will be released to the licensee, to confirm the issue in writing of the reported allegation and to request pertinent information regardless of the need to protect the identity of the alleger or the confidential information, if release of the information is necessary to protect public health, safety, environment, or security. In this instance, the 30-day waiting period (see subsection 6.4.3 following) will be waived.

6.4.2 Prohibitions on Referrals Do not refer the allegation to the licensee if any of the following apply:

  • The identity of the alleger or confidential source who has requested protection of identity, and confidential information, would be compromised by the information being released to the licensee unless the allegation raises an overriding safety concern.
  • The evaluation of the allegation would be compromised because of knowledge gained by the licensee.
  • The allegation is made against the licensee's management or those parties who would normally receive and address the allegation.
  • The allegation is based on information received from a federal agency that does not approve of the information being released to the licensee.
  • The alleger has previously addressed the allegation with the licensee with unsatisfactory results and/or the alleger objects to a referral.
  • Allegation involving criminal negligence, intentional or knowing behavior, or careless disregard.

Note: If the above criteria conflicts with those for public release as described in Attachment 2, discuss the referral with Office of Legal Counsel and the Enforcement Division of the Air Bureau.

RCP-904.1 Rev 0 2/8/2024 Page 16 of 27 RCP-904.1 Rev 0 2/8/2024 Page 16 of 27 6.4.3 Referral Criteria Consider the following when determining whether to refer an allegation(s) to a licensee:

  • Could the release of information bring harm to the alleger or confidential source?
  • Has the alleger or confidential source objected to the release of the allegation to the licensee?
  • What is the licensee's history of addressing allegations?
  • What is the likelihood that the licensee will effectively investigate, document, and resolve the allegation?
  • Is there any other relevant reason to withhold the information?

6.4.4 Informing the Alleger 6.4.4.1 Prior to referring an allegation to a licensee, make all reasonable efforts to inform the alleger or confidential source of the intent to refer, unless there is an overriding safety issue.

6.4.4.2 If the alleger or confidential source cannot be reached by telephone, then inform the alleger or confidential source by certified letter of the intent to refer the allegation to the licensee.

6.4.4.3 If the alleger or confidential source objects to the referral or does not respond to the letter within 30 calendar days, and the factors described in section 6.4.1 and 6.4.2 concerning the referral prohibitions and allowances and 6.3.2.5 concerning an overriding safety issue have been considered, then refer the allegation to the licensee.

RCP-904.1 Rev 0 2/8/2024 Page 17 of 27 RCP-904.1 Rev 0 2/8/2024 Page 17 of 27 6.4.5 Referral Letter to Licensee 6.4.5.1 Referrals should be made by SRCP or designated staff.

6.4.5.2 If a referral of an allegation is to be made to the licensee, then ensure the referral letter contains the following:

o A complete description of the elements of the allegation, excluding the identity of the alleger or confidential source, and any confidential information that could result in the licensee identifying the alleger or confidential source.

o A statement that the referral is a result of an allegation against the licensee.

o A request to the licensee to thoroughly review the elements of the allegation in a manner that is objective, of sufficient scope, and of sufficient depth to resolve the allegation.

o A written report of the results of the review must be submitted to the Department within 30 working days of receipt by the licensee of the referral letter.

6.4.5.3 If the allegation was received in writing, then do not include a copy or the original written information from the alleger or confidential source in the written referral to the licensee, unless written permission from the alleger or confidential source has been obtained.

6.4.5.4 Ensure a copy of the referral letter is added to the Allegation File.

6.4.6 Licensee Response 6.4.6.1 The SRCP is responsible for determining whether the licensee response is adequate and for directing further actions to be taken in response to the licensees review of an allegation.

6.4.6.2 Evaluation of the adequacy of licensees response is completed by considering, at a minimum, all the following factors:

o Was the evaluation conducted by an entity independent of the organization in which the alleged event occurred?

RCP-904.1 Rev 0 2/8/2024 Page 18 of 27 RCP-904.1 Rev 0 2/8/2024 Page 18 of 27 o Was the evaluator competent in the specific functional area in which the alleged event occurred?

o Was the evaluation of adequate depth to establish the scope of the problem?

o Was the scope of the evaluation sufficient to establish that the alleged event or problem was not a systemic defect?

o If the allegation was substantiated, did the evaluation consider the root cause and generic implications of the allegation?

o Was the licensee's corrective action sufficient to prevent, alleviate, or correct deficiencies in both the specific and generic instances, and in the short and long term?

6.4.6.3 If the licensee's response is adequate, then notify the licensee within 30 working days that the response is adequate and that no further action is required. The response will be incorporated in the closeout letter to the alleger or confidential source.

6.4.6.4 If the licensee's response is considered to be inadequate, then determine the additional actions required to resolve the allegation, including an investigation, enforcement actions (per RCP 902.1),

etc.

6.4.6.5 Ensure a copy of both the licensees response and the Departments response letter are entered into the Allegation File.

6.5 Investigations If the allegation cannot be referred to the licensee; is not resolved by the licensee; or, involves possible criminal negligence, behavior that is conducted intentionally, knowingly, or behavior that potentially meets the definition of careless disregard, an investigation shall be performed, preferably by the Lead Investigator. The investigation may be included as part of a routine inspection or may involve only the allegation(s).

6.5.1 When conducting an investigation in response to an allegation, use all of the following techniques:

  • Inspect the issue not the alleger or confidential source.

RCP-904.1 Rev 0 2/8/2024 Page 19 of 27 RCP-904.1 Rev 0 2/8/2024 Page 19 of 27

  • Avoid prejudgment.
  • Do not communicate that the specific issue was raised by an alleger or confidential source (See subsection 6.4.4).
  • Take extensive notes and obtain copies of pertinent records, if possible.
  • Interview employees regarding relevant procedures and activities.
  • Verify any assertions made by the licensee.

6.5.2 If investigation of the allegation is determined to have a negative impact on public health or safety or environment, immediately take action to mitigate the incident and immediately notify the SRCP (see RCP 904.2 Incident Response).

6.5.3 Notify the RCDP or designee to consult with legal counsel.

6.5.4 Document the results of the investigation in a written report and submit to RCPD or designee.

6.5.5 Ensure a copy of the investigation report is entered into the Allegation File.

6.5.6 Send a closeout letter to the alleger, if possible, documenting the results of the investigation.

6.6 Close Out 6.6.1 The RCPD or designee shall determine when there is sufficient information to close out the allegation and indicate in the investigation report or licensee response letter satisfactory response.

6.6.2 The Allegation File should be updated and closed. If appropriate, a copy of all information should be placed in the licensees file.

6.6.3 If contact information was provided, a letter should be reviewed by the RCPD or designee and sent to the alleger or confidential source of the findings of the allegation indicating that it has been considered closed.

RCP-904.1 Rev 0 2/8/2024 Page 20 of 27 RCP-904.1 Rev 0 2/8/2024 Page 20 of 27 6.6.4 Regardless of whether an investigation was conducted in response to the allegation or not, the Lead Investigator should place a note in the licensees file. Note: this documentation may be subject to FOIA.

6.6.5 If an incident was discovered through inspection or investigation, ensure all notifications required to NRC and NMED were made in accordance with RCP 904.2 Incident Response. Refer to RCP 904.2 for follow up guidelines. Refer to RCP 902.1 Enforcement, Escalated Enforcement, and Administrative Actions if enforcement actions are necessary. If the cause was a possible generic problem, notify other affected licensees.

6.7 Coordinating with Other Agencies 6.7.1 In the case of complaints or allegations involving other local, state, or federal agencys jurisdiction, the Radiation Control Physicist should withhold the information from the licensee and elevate the concerns to the attention of the SRCP, RCPD or designee while still onsite. The RCPD will make referrals as appropriate.

6.7.2 Allegations involving healthcare facilities shall be coordinated with the Connecticut Department of Public Health.

6.7.3 If, at any time, the need for criminal investigatory capacity is required, (for example thefts and/or terrorist activity, as described in Section 6.1.2) contact the Local Law Enforcement Agency (LLEA) and/or the Connecticut State Police and/or other state and federal agencies such as the U.S. Federal Bureau of Investigation (FBI), as appropriate. The FBI should be notified if an event involves the possibility of theft or terrorist activities. The Connecticut Department of Energy and Environmental Protection (Department) shall promptly notify the Nuclear Regulatory Commission (NRC) Operations Center (301-819-5100) after contacting the appropriate Law Enforcement Agency and/or FBI in cases involving actual or attempted theft, sabotage, or diversion of radioactive materials as indicated in Appendix G of NRC SA-300.

6.7.4 If the allegation involves federally recognized tribal land or federally licensed entity, the allegation should be referred to the Nuclear Regulatory Commission for handling. Allegations involving another Agreement State should be referred to the Agreement State Radiation Control Program by the RCPD or designee.

RCP-904.1 Rev 0 2/8/2024 Page 21 of 27 RCP-904.1 Rev 0 2/8/2024 Page 21 of 27 ATTACHMENTS Initial Contact Log Nondisclosure Statement Allegation Screening Form Confidential Information and Files Acknowledgement Letter to Alleger

RCP-904.1 Rev 0 2/8/2024 Page 22 of 27 RCP-904.1 Rev 0 2/8/2024 Page 22 of 27 ATTACHMENT 1 - Initial Contact Log INITIAL ALLEGATION CONTACT LOG INSTRUCTIONS:

This log is to be used to record the information gathered in an allegation against a licensee or registered user.

Inform the individual of the conditions regarding confidentiality:

The individual has requested to remain anonymous and requested that their personal identifying information not be documented.

Individual has declined anonymity and has been notified of potential disclosure in accordance with Attachment 2.

ALLEGER INFORMATION:

Individuals full name:

Telephone number:

Email Address:

Position or relationship to the facility or activity involved:

Allegers employer:

Home mailing address:

Facility / location:

What sort of activities or practices did this involve? What have they observed? Use back for additional information.

NATURE AND DETAILS OF THE ALLEGATION:

How long has this activity been occurring?

Description of the Concern Is this a current or past unsafe practice?

How did the individual find out about the concern?

Date(s) and times of occurrence:

Location of occurrence (if different) and directions (if needed)

Are there other individuals who should be contacted for additional information?

(list names, addresses, phone number if available)

What records does the individual think should be reviewed?

Has the individual raised the concerns with his/her management?

Yes What action has been taken?

No Why not?

RCP-904.1 Rev 0 2/8/2024 Page 23 of 27 RCP-904.1 Rev 0 2/8/2024 Page 23 of 27 If the allegation involves discrimination because of age, sex, race, etc., inform the alleger that they should contact the State of Connecticut Commission on Human Rights at (860) 541-3400.

    • If this allegation was forwarded from another agency, indicate who the contact was that provided the notification:

Agency:

Region/Office:

Name:

Telephone:

ACTIONS TO BE TAKEN:

Refer this to the Radiation Control Program Director If this issue was referred to another agency, please list the name of agency:

ADDITIONAL COMMENTS OR INFORMATION:

RCP-904.1 Rev 0 2/8/2024 Page 24 of 27 RCP-904.1 Rev 0 2/8/2024 Page 24 of 27 ATTACHMENT 2 NONDISCLOSURE STATEMENT I have information that I wish to provide in confidence to the Connecticut Department of Energy and Environmental Protection (Department), Radioactive Materials Program (RMP). I request that the RMP not reveal that I am the source of the information.

During an inquiry or investigation, the RMP will make its best effort to avoid actions that would clearly be expected to result in disclosure of my identity.

My identity may be divulged outside the RMP in any one or more of the following situations:

  • When disclosure is necessary because of an overriding safety issue. The RMP staff will attempt to contact me prior to any disclosure.
  • When a court orders such disclosure.
  • When the RMP requests disclosure for enforcement proceedings.
  • In response to a legislative request. While such a request will be handled on a case-by-case basis, the RMP will make its best effort to limit the disclosure to the extent possible.
  • When requested by a federal or state agency in furtherance of its statutory responsibilities and the RMP finds that furtherance of the public interest requires such release.
  • When the State of Connecticut Attorney General or a local or state law enforcement agency is pursuing an investigation, my identity may be disclosed without my knowledge or consent.
  • When I have taken actions that are inconsistent with and override the purpose of protecting my identity.
  • Disclosure is mandated by the Connecticut Freedom of Information Act.

My identity will be withheld from RMP staff, except on a need-to-know basis. Consequently, I acknowledge that if I have further contacts with RMP personnel, I cannot expect that those people will be cognizant of my desire to remain anonymous, and it will be my responsibility to bring that point to their attention if I desire similar treatment for the information provided to them.

I have read and fully understand the information above.

Signature: _____________________________________ Date: __________________________

Address: _____________________________________________________________________

Comments: (document if unable to obtain a signature or if nondisclosure read to anonymous alleger)

RCP-904.1 Rev 0 2/8/2024 Page 25 of 27 RCP-904.1 Rev 0 2/8/2024 Page 25 of 27 ATTACHMENT 3 ALLEGATION SCREENING FORM a)

Is there an immediate safety concern that must be quickly addressed?

b)

Is the allegation a specific safety or quality issue or a generalized concern?

c)

Has the staff previously addressed this issue or a similar issue?

d)

Have there been a substantial number of allegations on similar concerns?

e)

What is the time sensitivity of the allegation and what immediate actions are necessary?

f)

What is the potential for wrongdoing and will investigative assistance be needed?

g)

Does the allegation package contain sufficient information for a thorough evaluation? If not, identify the additional information needed.

h)

Can the issues be adequately addressed by a routine technical inspection? If not, determine the best way to address the issues.

i)

Is the identity of the alleger necessary for a thorough evaluation?

j)

Identify any peripheral issues that could develop.

k)

Are any licensing actions or enforcement actions pending that could be affected by the allegation? When an allegation involves a case with pending licensing action, the Radiological Health Specialist working on the case should be promptly notified.

l)

Can inspection resources be effectively utilized pursuing the issue or is the allegation too vague or frivolous?

m)

Is further consideration of the allegation required? If not, inform the alleger in a courteous and diplomatic manner of the rationale for not considering it further. Consult the Radiation Control Program Director, Supervising Radiation Control Physicist, and the Office of Legal Counsel for a final decision before doing so.

n)

Can licensee resources reasonably be used in resolving the allegation to conserve staff resources?

o)

Does the allegation have the potential to require escalated enforcement action?

RCP-904.1 Rev 0 2/8/2024 Page 26 of 27 RCP-904.1 Rev 0 2/8/2024 Page 26 of 27 ATTACHMENT 4 CONFIDENTIAL INFORMATION AND FILES Upon receipt of an allegation and during the investigation of an allegation, the alleger may request and reasonably expect that his/her identity will be protected as confidential information, except for the situations outlined Attachment 2. Basic rules to protect the identity of the alleger and other confidential information are outlined below.

1) Restrict staff discussions to those individuals who truly need-to-know.

The allegers identity and other information that would reveal their identity should be withheld from other Radioactive Materials Program staff not involved with the investigation.

2) Restrict access to the hardcopy and computer files by storing in a secure file.

All information regarding the allegers identity and other confidential information will be stored in the specific Allegations File. The Allegation File will be maintained in a padlocked filing cabinet and an electronic folder accessible only to the RCPD or designee and SRCP.

When an electronic or paper copy is in use by the RCPD or designee or SRCP, he or she is responsible for controlling access to it at all times when the file is not locked up or closed electronically.

3) Protect access to information during work.

Files are not left lying open if the work area is not occupied. Computer screens are not left open if the work area is not occupied. At the end of the day, the hardcopy Allegation File is placed in the padlocked secure file. Computer files are saved on the secured computer space.

Drafts are not developed outside this computer space. Field notes, received forms, etc. are kept secured or are disposed of.

4) Be wary of faxes and e-mails if you must use them.

Faxes are sent being very careful to enter the correct telephone number. Calls should be made prior to sending a fax to alert the recipient and a confirmation call should be made to confirm the fax was received. Generally, it is not prudent to use e-mail to transmit confidential information.

5) Ensure that reports and correspondence to other entities do not contain information that could lead to the identification of the alleger or confidential source or other confidential information.

Other entities could include: the licensee, applicant, the Nuclear Regulatory Commission or other federal agency, another state or local agency, or another agreement state. If the RMP has chosen to refer the allegation to the licensee, the original information submitted by the alleger should be omitted. The information should be re-worded to reflect the basic facts and any language should be removed that could be used to identify the alleger.

RCP-904.1 Rev 0 2/8/2024 Page 27 of 27 RCP-904.1 Rev 0 2/8/2024 Page 27 of 27 ATTACHMENT 5 ACKNOWLEDGEMENT LETTER TO ALLEGER

<Utilize Department letterhead>

Date Mr. John Doe 1234 Abc Street Anytown, CT 06###

Docket #

Dear Mr. Doe:

This letter refers to your contact with <specify individual> of the Connecticut Department of Energy and Environmental Protection (Department), Radioactive Materials Program (RMP) on

<specify date>, in which you expressed concern related to <specify licensee/company/etc.>.

<Specify concern e.g., you were concerned that you used a Troxler portable gauge without receiving proper training and transported the device in your personal vehicle.>

In addition, according to your contact with RMP staff, we understand that you did/did not object to having your allegation referred to <specify licensee/company/etc.>.

<Specify actions taken in response and include detailed information such as: on October 18th RMP staff performed a routine health and safety inspection of Company X and focused on an investigation of your allegation. During this investigation, RMP staff determined that you logged out the Troxler portable gauge at the Sample Jobsite in July prior to your August 2nd training certificate. Specify any other relevant information found related to the allegation such as: We were also able to determine that authorized users including yourself were allowed to perform work with the portable gauge without being issued dosimetry, which is a violation of the license.>

<Specify agency actions such as: subsequently, the Department has issued violations based upon the inspection and investigation.>

If you have any questions or further concerns, please contact me at <specify contact number> or

<specify email address>.

Sincerely, Name Title

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