ML24087A014

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Template - Draft Impep Report - (20240809)
ML24087A014
Person / Time
Issue date: 05/13/2024
From: Adelaide Giantelli
NRC/NMSS/DMSST/ASPB
To:
References
Download: ML24087A014 (1)
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Text

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001

((date:long

[Addressee] [Street Address] [City, State Zip Code]

SUBJECT:

STATE DRAFT IMPEP REPORT

Dear [Addressee (Mgt. above the RCPD)]:

The U.S. Nuclear Regulatory Commission (NRC) uses the Integrated Materials Performance Evaluation Program (IMPEP) to review radiation control programs. The enclosed draft report documents the results of the [State] Agreement State Program (State) review conducted on [START DATE-END DATE]. The teams preliminary findings were discussed with [State] on the last day of the review. The teams proposed recommendations are that [S TATE] be found adequate to protect public health and safety and compatible with the NRCs program.

The NRC conducts periodic reviews of radiation control programs to ensure that public health and safety are adequately protected from the potential hazards associated with the use of radioactive materials and that Agreement State programs are compatible with the NRCs program. The IMPEP reviews are conducted by a team of Agreement State and NRC staff. All reviews use common criteria in the assessment and place primary emphasis on performance. The final determination of adequacy and compatibility of each program, based on the teams report, is made by the Management Review Board (MRB) Chair after receiving input from the MRB members, the IMPEP team, and the radiation control program being reviewed. The MRB is composed of NRC senior managers and an Organization of Agreement States program manager.

In accordance with the IMPEP implementation procedures, the NRC is providing you with a copy of the draft report for your review and comment prior to submitting the report to the MRB. Comments are requested within 28 days. This schedule will permit the issuance of the final report in a timely manner. If there are no comments to the IMPEP report, the MRB will receive the draft IMPEP report. If there are comments to the report, the team will review your response, make the necessary changes, and issue a proposed final report to the MRB.

The MRB meeting is scheduled to be conducted as a hybrid meeting on [DATE], at [TIME] ET via Microsoft Teams. The NRC will provide you with Microsoft Teams connection information prior to the MRB meeting. Because the team has recommended all indicators be rated satisfactory, you have the option to attend the MRB meeting remotely and do not need to travel. OR The NRC will also provide invitational travel for you or your designee to attend the MRB meeting at the NRC Headquarters in Rockville, Maryland.

x. last name

If you have any questions regarding the enclosed report, please contact Robert K. Johson, IMPEP Project Manager, at ( 301) 415-7314 OR IMPEP Team Leader, at xxx-xxx-xxxx.

Thank you for your cooperation.

Sincerely,

((signature: ASG2}}

Adelaide S. Giantelli, Chief State Agreement and Liaison Programs Branch Division of Materials Safety, Security, State, and Tribal Programs Office of Nuclear Material Safety and Safeguards

Enclosure:

[STATE] Draft IMPEP Report

cc: [Program Manager, Position Title,] [Program Manager, Position Title,] [Program Manager, Position Title,]

OFFICE TL NMSS/MSST NMSS/MSST

NAME [TLeader] RJohnson AGiantelli DATE INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF THE [ AGREEMENT STATE OR NRC] AGREEMENT STATE PROGRAM

DATE-DATE, YEAR

DRAFT REPORT [GENERAL NOTES]:

  • When referencing the Agreement State Program, be consistent and use the

[STATE], versus the term Program. ;

  • Radioactive material program has been replaced with radiation control program;
  • Run spelling and grammar check (or Editor) prior to submission to IMPEP PM;
  • Numbers: spell out numbers from one through nine; and use numerals for a single number of 10 or more, except as noted in the NRC Style Guide (e.g., use numerals to express unit of measurement, such as time or percent);
  • Do not start a sentence with an acronym, even if its been used and defined previously;
  • Limit statements to facts affecting performance, not hearsay or assumptions;
  • Avoid using qualifiers, e.g., generally, mostly or the majority of; use specific numbers instead (e.g., 10 of the 15 reviewed, 90 percent, etc.);
  • Provide enough detail especially when performance-based issues are found, for the next team to review thoroughly;
  • Make recommendations for issues involving specific problems within the indicator, not for issues that are basically required by the indicator(s);
  • Ensure 1 space after a colon and a period;
  • Do not begin sentences with the word However ;
  • Do not use words like lack or failure;
  • Since IMPEP is a look back, try to use past tense; and
  • Do not use hard returns or breaks of any kind at the end of pages.

Enclosure EXECUTIVE

SUMMARY

The results of the Integrated Materials Performance Evaluation Program (IMPEP) review of the [STATE Agreement State Program (STATE) or Nuclear Regulatory Commission (NRC)] are discussed in this report. The review was conducted in -person from [MONTH DATE-DATE, YEAR]. In-person inspector accompaniments were conducted during the week of [WEEK].

The team found [STATE/NRC program] s performance to be satisfactory for [all OR the following [number/all] performance indicator(s): [Select from this LIST: Technical Staffing and Training; Status of Materials Inspection Program; Technical Quality of Inspections; Technical Quality of Licensing Actions; Technical Quality of Incident and Allegation Activities; Legislation, Regulations, and Other Program Elements; Sealed Source and Device Evaluation Program; Low-Level Radioactive Waste Disposal Program; and UR Program. [For the NRC review: use commas to separate the performance indicators.)) performance indicator(s)]. The team also found [STATE/NRC program]s performance to be [ satisfactory but needs improvement or unsatisfactory] for the following [number] performance indicators: [LIST INDICATORS].

The team [did not make any new recommendations OR made [#] new recommendations and] determined that the recommendation(s) from the [YEAR] IMPEP review should be closed and/or, believe that the previous recommendation(s) [regarding (e.g., regulation adoption/document security markings/development and implementation of a formal training program/etc.) should remain open] OR [there were no recommendations from the previous review for the team to consider].

Accordingly, the team recommends that the [STATE/NRC] radiation control program be found [adequate to protect public health and safety/adequate to protect public health and safety but needs improvement, or not adequate to protect public health and safety] and [compatible/not compatible] with the NRC's program. The team recommends that a periodic meeting take in approximately [#] years with the next IMPEP review taking place in approximately [#] years. [Further, the team recommended that the period of [HEIGHTENED OVER SIGHT or MONITORING] be [IMPOSED or TERMINATED)). [STATE or NRC] Draft IMPEP Report Page 1

1.0 INTRODUCTION

The ((STATE] Agreement State Program (STATE) OR [Nuclear Regulatory Commission (NRC))) Integrated Materials Performance Evaluation Program (IMPEP) review was conducted on [Month DATE-DATE, YEAR], by a team of technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and the [STATE/C OMMONWEALTH] of [NAME]. Team members are identified in Appendix A. In-person inspector accompaniments were conducted during on or between [START DATE-END DATE]. The in-person inspector accompaniments are identified in Appendix B. The review was conducted in accordance with the Agreement State Program Policy Statement, published in the Federal Register on October 18, 2017 (82 FR 48535), and NRC Management Directive (MD) 5.6, Integrated Materials Performance Evaluation Program (IMPEP), dated Jul y 24, 2019. Preliminary results of the review, which covered the period of [DATE] -[DATE], were discussed with [STATE/NRC] managers on the last day of the review.

In preparation for the review, a questionnaire addressing the common performance indicators and applicable non-common performance indicators was sent to [insert STATE/COMMONWEALTH /NRC] on [DATE]. [STATE/COMMONWEALTH /NRC] provided its response to the questionnaire on [ DATE]. A copy of the questionnaire response is available in the NRCs Agencywide Documents Access and Management System Accession Number MLxxxxxxxxx hyperlink.

The [STATE/ COMMONWEALTH /NRC] is administered by insert organizational hierarchy for example, Agreement State Program is administered by the Bureau of Radiation Control which is located within the Division of Emergency Preparedness and Community Support in the Department of Health. Organization charts for [insert STATE/COMMONWEALTH /NRC] are available in MLxxxxxxxxx hyperlink.

At the time of the review, [STATE/COMMONWEALTH /NRC] regulated [#] specific licenses authorizing possession and use of radioactive materials. The review focused on the radiation control program as it is carried out under Section 274b. (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC and the [ STATE OR COMMONWEALTH] of [STATE]. [FOR NRC USE : The review focused on the NRCs radiation control program as carried out under Section 161 of the Atomic Energy Act of 1954, as amended.]

The team evaluated the information gathered against the established criteria for each common and applicable non-common performance [indicator(s) ] and made a preliminary assessment of the [STATEs OR NRCs ] performance.

2.0 PREVIOUS IMPEP REVIEW AND STATUS OF RECOMMENDATIONS

The previous IMPEP review concluded on [DATE]. The final report is available in MLxxxxxxxxx hyperlink. The results of the review [and the status of the associated recommendation(s) - include only if applicable] are as follows:

[Under the appropriate indicator below, list the previous finding, details about any indicator found less than satisfactory during the last review and actions taken to improve the rating (if appropriate), and any open recommendation(s), including a brief explanation why the recommendation should be closed/modified/kept open.]

Technical Staffing and Training: (Satisfactory, Satisfactory but Needs Improvement, or Unsatisfactory)

[STATE or NRC] Draft IMPEP Report Page 2

If an indicator was found less than satisfactory at the last IMPEP review and the current team is recommending that the indicator be upgraded, then include a brief statement about the reasons for the deficiencies noted during the last review and any corrective actions the program has taken to address these deficiencies. For example : While there were no formal recommendations made in this area, the 202X IMPEP team noted that [STATEs] training program was missing specific required training courses and there was significant staff turnover during this review period.

In response, [STATE] developed a corrective action plan which reviewing all staff qualifications, identifying which training courses were needed and ensuring applying for these courses as soon as possible. Management also evaluated the reason for the high turnover and started making changes to salaries and benefits.

The 202X IMPEP team noted that the deficiencies identified in this indicator during the 202 4 review had been corrected and that sustained performance over this review period had been demonstrated. See Section 3.1 for additional details.

Recommendation: [if applicable or None] [For example]: The 203X team recommends that [ STATE] take additional actions, such as increasing salary and/or benefits, to stabilize staffing and ensure successful program implementation. (Section 3.1 of the 2009 IMPEP report)

Status: [if applicable] [For example]: In an effort to address the high staff turnover rate experienced by [STATE] in recent years, management increased starting salaries and introduced flexible work hours, resulting in a better work-life balance. Management ga ve the staff more ownership of the process. Staff members are now part of the decision-making process, are involved in the development of processes and procedures, and are involved in workload distribution. Overall, management responded in a positive manner to these performance issues.

The team recommends that this recommendation be closed.

Status of Materials Inspection Program: [Satisfactory, Satisfactory but Needs Improvement, or Unsatisfactory] Recommendation: [if applicable; or None] Status: [if applicable]

Technical Quality of Inspections: [Satisfactory, Satisfactory but Needs Improvement, or Unsatisfactory] Recommendation: [if applicable; or None] Status: [if applicable]

If an indicator was found less than satisfactory at the last IMPEP review and the current team is recommending that the indicator be upgraded, then include a brief statement about the reasons for the deficiencies noted during the last review and any corrective actions the program has taken to address these deficiencies. For example: While there were no formal recommendations made in this area, the 202X IMPEP team noted that during inspector accompaniments, inspectors did not consistently identify important health, safety, or security items, specifically with respect to completeness and thoroughness of the inspection.

[STATE or NRC] Draft IMPEP Report Page 3

In response, Program management developed a corrective action plan which included providing guidance to the inspection staff regarding the use of existing inspection guidance, as well as the expectation to use performance-based inspection techniques. Re-inspections of licensees were performed where inspector accompaniments identified technical deficiencies, and Program management set clear expectations for the inspection of security-related inspections. There was also a renewed management commitment to increased oversight of the inspection program.

The 202X IMPEP team noted that the deficiencies identified in this indicator during the 2014 review had been corrected and that sustained performance over this review period had been demonstrated. See Section 3.3 for additional details.

Technical Quality of Licensing Actions: [Satisfactory, Satisfactory but Needs Improvement, or Unsatisfactory] Recommendation: [if applicable; or None] Status: [if applicable]

Technical Quality of Incident and Allegation Activities: [Satisfactory, Satisfactory but Needs Improvement, or Unsatisfactory] Recommendation: [if applicable; or None] Status: [if applicable]

[List all applicable non-common performance indicators in same manner as above]

Overall finding: [Adequate to protect public health and safety/Adequate to protect public health and safety, but needs improvement, or Not Adequate to protect public health and safety] and [compatible/not compatible] with the NRC's program. [Mention if the program was placed on, or removed from, a period of heightened oversight or monitoring. (e.g., Based on the results of the 20xx [STATE] IMPEP review, the team recommended, and the Management Review Board (MRB) agreed, that NRC initiate a period of [HEIGHTENED OVESIGHT or MONITORING] for [STATE]. The team further recommended, and the MRB agreed, that a Periodic Meeting be held within [ #] year(s) and that a follow-up IMPEP review take place approximately [#] year(s) following the Periodic Meeting) ]

3.0 COMMON PERFORMANCE INDICATORS

Five common performance indicators are used to review the NRC and Agreement State radiation control programs. These indicators are: (1) Technical Staffing and Training, (2) Status of Materials Inspection Program, (3) Technical Quality of Inspections, (4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation Activities.

3.1 Technical Staffing and Training

The ability to conduct effective licensing and inspection programs is largely dependent on having experienced, knowledgeable, well-trained technical personnel. Under certain conditions, staff turnover could have an adverse effect on the implementation of these programs and could affect public health and safety. Apparent trends in staffing must be assessed. Review of staffing also requires consideration and evaluation of the levels of training and qualification. The evaluation standard measures the overall quality of training available to, and taken by, materials program personnel.

a. Scope

[STATE or NRC] Draft IMPEP Report Page 4

The team used the guidance in State Agreements procedure (SA) SA-103, Reviewing the Common Performance Indicator: Technical Staffing and Training, and evaluated [STATE/COMMONWEALTH/NRC]s performance with respect to the following performance indicator objectives:

  • A well-conceived and balanced staffing strategy has been implemented throughout the review period.
  • Any vacancies, especially senior-level positions, are filled in a timely manner.
  • There is a balance in staffing of the licensing and inspection programs.
  • Management is committed to training and staff qualification.
* [Agreement State training and qualification program is equivalent to NRC Inspection Manual Chapter (IMC) IMC 1248, Formal Qualifications Program for Federal and State Material and Environmental Management Programs. - use only for State reviews]
  • Qualification criteria for new technical staff are established and are followed, or qualification criteria will be established if new staff members are hired.
  • Individuals performing materials licensing and inspection activities are adequately qualified and trained to perform their duties.
  • License reviewers and inspectors are trained and qualified in a reasonable period.
b. Discussion

[STATE/ COMMONWEALTH/The NRC] is comprised of [#] staff members [or [#] technical staff members and [#] administrative staff members] which equals [#] full-time equivalent (FTE) for the radiation control program when fully staffed. T here were [# or no] vacancies at the time of the on-site review. During the review period, [#] of the staff members left the program and [#] staff members were hired. The positions were vacant from [X to Y (days, weeks, months, etc.) give the range of time, e.g., 6 to 9 months]. The team noted that [STATE/ COMMONWEALTH/ The NRC]s training and qualification program was [compatible with the NRCs IMC 1248] OR [not compatible and why]. [If this results in performance problems, explain in the Evaluation section below.]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the status of corrective actions taken by the STATE.]

[List the recommendation(s) below the paragraph describing the performance issue.]

[For example]: [STATE] had two senior health physicist vacancies in January 202 1 because two senior staff members left the STATE for higher paying positions in the private sector. In February 202 1, two individuals were promoted into these positions, which created two new vacancies. These positions were not filled until June 202 2 due to a lack of qualified candidates and pay freezes. The loss of two senior staff members resulted in the [STATE] [e.g., accruing a backlog of licensing actions, postponement of/missed inspections, reduced/delayed responses to incidents, impacted the States ability to provide timely notifications to the NRC, etc. These are a few examples of performance problems. The key is to explain the performance impact [STATE or NRC] Draft IMPEP Report Page 5

to the P rogram]. At the time of the review, the [STATEs] program had recovered from the loss of the senior staff and the newly hired staff has been fully trained. [List the recommendation(s) at the end of the paragraph describing the performance issue, e.g., The team recommends that the [STATE] take additional actions, such as increasing salary and/or benefits, to stabilize staffing and retention to ensure successful program implementation.].

[If the STATE encountered pandemic related impacts that were outside of their control, then refer to the guidance provided TI-003 to address any impacts in the discussion.] Temporary Instruction (TI) 003, Evaluating the Impacts of the COVID -19 Public Health Emergency as part of the Integrated Materials Performance Evaluation Program, states, in part, that license reviewers and inspectors may take longer to become qualified due to the inability to travel to attend training classes needed to complete qualification and inspections being delayed due to social distancing or other factors related to the pandemic, provided [STATE/COMMONWEALTH] continued to maintain health, safety, and security. The team noted that although the pandemic had reduced the number of in-person training opportunities, [STATE/COMMONWEALTH] s staff continued to enroll in NRC virtual classes, when available. The team noted that although the pandemic had reduced the number of in-person training opportunities for its staff, [STATE/COMMONWEALTH] continued to work with the Organization of Agreement States and the NRCs Technical Training Center to take advantage of NRC on-line training classes.

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

c. Evaluation

[If there are no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/ COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.1.a. Based on the criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Staffing and Training, be found satisfactory.

[If there are performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/ COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.1.a, except for: 

* [Provide a bulleted list of the performance indicator(s) objective(s) the State/NRC program did not meet indicating how the State/NRC program was deficient. For example: Vacancies were not filled in a timely manner.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the [STATE/ COMMONWEALTH/NRC], and the current status of the performance issue.] Add recommendation(s) here.

[STATE or NRC] Draft IMPEP Report Page 6

[If there are performance problems, explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[For example]: The team considered recommending a finding of unsatisfactory for this indicator, but concluded that there was no performance issue associated with licensing, inspection, or response to incidents.

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/the NRC]s performance with respect to the indicator, Technical Staffing and Training, be found [satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to closing/keeping open /making new and old recommendations?

d. Management Review Board (MRB) Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

3.2 Status of Materials Inspection Program

Inspections of licensed operations are essential to ensure that activities are being conducted in compliance with regulatory requirements and consistent with good safety and security practices. The frequency of inspections is specified in IMC 2800, Materials Inspection Program, and is dependent on the amount and type of radioactive material, the type of operation licensed, and the results of previous inspections. There must be a capability for maintaining and retrieving statistical data on the status of the inspection program.

a. Scope

The team used the guidance in SA-101, Reviewing the Common Performance Indicator: Status of the Materials Inspection Program, and evaluated [STATE/COMMONWEALTH/NRC]s performance with respect to the following performance indicator objectives:

  • Initial inspections and inspections of Priority 1, 2, and 3 licensees are performed at the prescribed frequencies (https://www.nrc.gov/materials/miau/mat-toolkits.html).
  • Deviations from inspection schedules are normally coordinated between technical staff and management.
  • There is a plan to perform any overdue inspections and reschedule any missed or deferred inspections or a basis has been established for not performing any overdue inspections or rescheduling any missed or deferred inspections.
  • Candidate licensees working under reciprocity are inspected in accordance with the criteria prescribed in IMC 2800 and other applicable guidance or compatible Agreement State Procedure.
  • Inspection findings are communicated to licensees in a timely manner (30 calendar days, or 45 days for a team inspection), as specified in IMC 0610, Nuclear Material Safety and Safeguards Inspection Reports.

[STATE or NRC] Draft IMPEP Report Page 7

b. Discussion

[STATE/COMMONWEALTH/NRC] performed [#] Priority 1, 2, 3, and initial inspections during the review period. [STATE/COMMONWEALTH /The NRC] conducted [#] percent of Priority 1, 2, 3, and initial inspections overdue OR No Priority 1, 2, 3 or initial inspections were conducted overdue during the review period. [If the number is >0, then state how many, e.g., [X of Y] Priority 1, 2, or 3, and [X of Y] initial inspections were conducted overdue. IF the overdue inspections were impacted by pandemic and out of the States control, then use the Guidance in TI-003 to identify the number of inspection that were outside of their control and the impact on the overall results (e.g. The team noted that TI- 003 states, in part, that for inspections that exceed the scheduling window with overdue dates falling inside the defined time frame of the pandemic, the number of overdue inspections should be noted in the report but should not be counted,, provided that the STATE continues to maintain health, safety, and security. Provide a sentence like.STATE continued to maintain health, safety, and security during this time frame. Of the overdue inspections noted above, [X] initial inspection was performed overdue and [Y] initial inspection was overdue at the time of the IMPEP review due to impacts related to the pandemic. Therefore, the team did not include these [Z] inspections when performing the calculation.]

[STATE/COMMONWEALTHs] inspection frequencies were the [same, more frequent, less frequent] for similar license types in NRCs program.

A sampling of [#] inspection reports indicated that [none or #] of the inspection findings were communicated to the licensees beyond [STATE/COMMONWEALTH /the NRC]s goal of 30 days after the inspection exit or 45 days after the team inspection exit.

Insert a paragraph describing how the r adiation control program conducts reciprocity inspections.

[Add details addressing noteworthy aspects of the P rogram, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. Put the percentage of overdue inspections in context.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

c. Evaluation

[If there are no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/ COMMONWEALTH/the NRC] met the performance indicator objectives listed in Section 3.2.a. Based on the criteria in MD [STATE or NRC] Draft IMPEP Report Page 8

5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Status of Materials Inspection Program, be found satisfactory.

[If there are performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.2.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the STATE/NRC program did not meet indicating how the STATE/NRC program was deficient. For example:

Inspection findings were not communicated to licensees in a timely manner (30 calendar days, or 45 days for a team inspection). ]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. List any recommendation(s).]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/ NRC]s performance with respect to the indicator, Status of Materials Inspection Program, be found [ satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

3.3 Technical Quality of Inspections

Inspections, both routine and reactive, provide reasonable assurance that licensee activities are carried out in a safe and secure manner. Accompaniments of inspectors performing inspections and the critical evaluation of inspection records are used to assess the technical quality of an inspection program.

a. Scope

The team used the guidance in SA-102, Reviewing the Common Performance Indicator: Technical Quality of Inspections, and evaluated [S TATE/COMMONWEALTH/NRC]s performance with respect to the following performance indicator objectives:

  • Inspections of licensed activities focus on health, safety, and security.
  • Inspection findings are well-founded and properly documented in reports.
  • Management promptly reviews inspection results.
  • Procedures are in place and used to help identify root causes and poor licensee

[STATE or NRC] Draft IMPEP Report Page 9

performance.

  • Inspections address previously identified open items and violations.
  • Inspection findings lead to appropriate and prompt regulatory action.
  • Supervisors, or senior staff as appropriate, conduct annual accompaniments of each inspector to assess performance and assure consistent application of inspection policies.
  • For Programs with separate licensing and inspection staffs, procedures are established and followed to provide feedback information to license reviewers.
* [Inspection guides are compatible with NRC guidance. - only for Agreement State reviews]
  • An adequate supply of calibrated survey instruments is available to support the inspection program.
b. Discussion

The team evaluated [#] inspection reports and enforcement documentation, and interviewed inspectors involved in materials inspections conducted during the review period. The team reviewed casework for inspections conducted by [#] of [STATE/COMMONWEALTH/NRC]s inspectors and covered medical, industrial, commercial, academic, research, and service licenses.

[A team member OR Team members] accompanied [#] inspectors on [DATES]. The in-person inspector accompaniments are identified in Appendix B. Provide summary of inspector accompaniments: The team determined that the inspectors performances observed during the inspector accompaniments indicated that the inspectors were knowledgeable of the requirements for each license type and were able to identify potential health, safety, and security concerns.

[If supervisory accompaniments were not conducted annually for all inspectors, insert a sentence which explains why in any given year an accompaniment was not performed.] [If this resulted in performance problems, explain in the Evaluation section below].

[Add details about the pandemic impact to the inspection program, as appropriate.]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at https://www.nrc.gov/materials/toolboxes/impep/team-leader.html] [Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

Add sentence or two about radiation detection equipment.

c. Evaluation

[STATE or NRC] Draft IMPEP Report Page 10

[If there are no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.3.a. Based on the criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Quality of Inspections be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[If there are performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.3.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the STATE/NRC program did not meet indicating how the STATE/NRC program was deficient. For example:

Inspections did not address previously identified open items and violations.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. New recommendations?]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Quality of Inspections, be found [satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

3.4 Technical Quality of Licensing Actions

The quality, thoroughness, and timeliness of licensing actions can have a direct bearing on public health and safety, as well as security. An assessment of licensing procedures, implementation of those procedures, and documentation of communications and associated actions between the [STATE/COMMONWEALTH/NRC] licensing staff and regulated community is a significant indicator of the overall quality of the licensing program.

a. Scope

[STATE or NRC] Draft IMPEP Report Page 11

The team used the guidance in SA-104, Reviewing the Common Performance Indicator: Technical Quality of Licensing Actions, and evaluated [STATE/COMMONWEALTH/NRC] s performance with respect to the following performance indicator objectives:

  • Licensing action reviews are thorough, complete, consistent, and of acceptable technical quality with health, safety, and security issues properly addressed.
  • Essential elements of license applications have been submitted and elements are consistent with current regulatory guidance (e.g., pre-licensing guidance, Title 10 of the Code of F ederal Regulations ( 10 CFR) Part 37, financial assurance, etc.).
  • License reviewers, if applicable, have the proper signature authority for the cases they review independently.
  • License conditions are stated clearly and can be inspected.
  • Deficiency letters clearly state regulatory positions and are used at the proper time.
  • Reviews of renewal applications demonstrate a thorough analysis of a licensees inspection and enforcement history.
  • Applicable guidance documents are available to reviewers and are followed (e.g.,

NUREG-1556 series, pre-licensing guidance, regulatory guides, etc.).

  • Licensing practices for risk-significant radioactive materials are appropriately implemented including the physical protection of Category 1 and Category 2 quantities of radioactive material (10 CFR Part 37 equivalent).
  • Documents containing sensitive security information are properly marked, handled, controlled, and secured.
b. Discussion

During the review period, [STATE/COMMONWEALTH/NRC ] performed [#] radioactive materials licensing actions. The team evaluated [#] of those licensing actions. The licensing actions selected for review included [#] new applications, [#] amendments, [#] renewals, [#] terminations, etc. The team evaluated casework which included the following license types and actions: [e.g., broad scope, medical diagnostic and theraputic, accelerator, commercial manufacturing and distribution, industrial radiography, research and development, academic, nuclear pharmacy, gauges, panoramic and self-shielded irradiators, well-logging, service providers, waste brokers, decommissioning, financial assurance, bankruptcies, change of ownership notifications, etc.]. The casework sample represented work from [#] license reviewers.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

[STATE or NRC] Draft IMPEP Report Page 12

Add sentences about Pre-Licensing Guidance checklist, RSRM checklist, licensing guidance (NUREG-1556, medical licensing guidance, etc. ), and protection of sensitive information.

c. Evaluation

[If there are no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.4.a. Based on the criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[If there are performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.4.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the STATE/NRC program did not meet indicating how the STATE/NRC program was deficient. For example:

Documents containing sensitive security information are not properly marked, handled, controlled, and secured.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. New recommendation?]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC] s performance with respect to the indicator, Technical Quality of Licensing Actions, be found [satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

3.5 Technical Quality of Incident and Allegation Activities

The quality, thoroughness, and timeliness of response to incidents and allegations of safety concerns can have a direct bearing on public health, safety and security. An assessment of incident response and allegation investigation procedures, actual implementation of these [STATE or NRC] Draft IMPEP Report Page 13

procedures internal and external coordination, timely incident reporting, and investigative and follow-up actions, are a significant indicator of the overall quality of the incident response and allegation programs.

a. Scope

The team used the guidance in SA-105, Reviewing the Common Performance Indicator: Technical Quality of Incident and Allegation Activities, and evaluated [STATE/COMMONWEALTH/NRC] s performance with respect to the following performance indicator objectives:

  • Incident response and allegation procedures are in place and followed.
  • Response actions are appropriate, well-coordinated, and timely.
  • On-site responses are performed when incidents have potential health, safety, or security significance.
  • Appropriate follow-up actions are taken to ensure prompt compliance by licensees.
  • Follow-up inspections are scheduled and completed, as necessary.
  • Notifications are made to the NRC Headquarters Operations Center for incidents requiring a 24-hour or immediate notification to the Agreement State or NRC.
  • Incidents are reported to the Nuclear Material Events Database (NMED) and closed when all required information has been obtained.
  • Allegations are investigated in a prompt, appropriate manner.
  • Concerned individuals are notified within 30 days of investigation conclusions.
  • Concerned individuals identities are protected, as allowed by law.
b. Discussion

During the review period, [#] incidents were reported to [STATE/COMMONWEALTH/NRC ]. The team evaluated [#] radioactive materials incidents which included [#] lost or stolen radioactive materials, [#] potential overexposures, [#] medical events, [#] damaged equipment, [#] radioagraphy source disconnects, [#] leaking sources, etc. The [STATE/COMMONWEALTH/NRC] dispatched inspectors for on-site follow-up for [#] of the cases reviewed.

[IF APPLCABLE: When notified of an incident, management and staff meet to discuss the incident and determine the appropriate level of response, which can range from an immediate response to reviewing the incident during the next routine scheduled inspection. Those determinations were made based on both the circumstances and the health and safety significance of the incident. The team found that [STATE] s evaluation of incident notifications and its response to those incidents was thorough, well balanced, complete, and comprehensive.]

The team also evaluated the [STATEs] reporting of incidents to the NRCs Headquarters Operations Officer (HOO). The team noted that in each case requiring HOO notification, the [STATE] reported the incidents within the required time frame. The team also evaluated whether the [STATE] had not reported any required incidents to the HOO. The team did not identify any missed reporting requirements.

During the review period, [#] allegation(s) were received by [STATE/COMMONWEALTH/NRC]. The team evaluated [#] allegations, including [#] allegations that the NRC referred to the State, during the review period.

[Add details addressing noteworthy aspects of the program, i.e., things the [STATE or NRC] Draft IMPEP Report Page 14

STATE/NRC does particularly well.]

[Add details about the pandemic impact to the inspection program, as appropriate.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the program, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

c. Evaluation

[If there are no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.5.a. Based on the criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Quality of Incident and Allegation Activities, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[If there are performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 3.5.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the STATE/NRC program did not meet indicating how the STATE/NRC program was deficient. For example:

Incidents are reported to the Nuclear Material Events Database (NMED), but have not been closed when all required information has been obtained.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. New recommendation?]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

[STATE or NRC] Draft IMPEP Report Page 15

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Technical Quality of Incident and Allegation Activities, be found [satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

4.0 NON-COMMON PERFORMANCE INDICATORS

Four non-common performance indicators are used to review Agreement State programs: (1) Legislation, Regulations, and Other Program Elements; (2) Sealed Source and Device (SS&D) Evaluation Program; (3) Low-Level Radioactive Waste (LLRW) Disposal Program; and (4) Uranium Recovery (UR) Program. The NRC retains regulatory authority for [SS&D Evaluation, LLRW Disposal, and/ or UR Program(s)]; therefore, only the first [#] non-common performance [indicator(s)] applied to this review. OR Two non-common performance indicators are used to review the NRCs program: (1) SS&D Evaluation and (2) UR Programs.

4.1 Legislation, Regulations, and Other Program Elements

State statutes should authorize the State to establish a program for the regulation of agreement material and provide authority for the assumption of regulatory responsibility under the States agreement with the NRC. The statutes must authorize the State to promulgate regulatory requirements necessary to provide reasonable assurance of adequate protection of public health, safety, and security. The State must be authorized through its legal authority to license, inspect, and enforce legally binding requirements, such as regulations and licenses. The NRC regulations that should be adopted by an Agreement State for purposes of compatibility or health and safety should be adopted in a time frame so that the effective date of the State requirement is not later than 3 years after the effective date of the NRC's final rule. Other program elements that have been designated as necessary for maintenance of an adequate and compatible program should be adopted and implemented by an Agreement State within 6 months following NRC designation. A Program Element Table indicating the Compatibility Categories for those program elements other than regulations can be found on the NRC W eb site at the following address: https://scp.nrc.gov/regtoolbox.html.

a. Scope

The team used the guidance in SA-107, Reviewing the Non-Common Performance Indicator: Legislation, Regulations, and Other Program Elements, and evaluated [S TATEs] performance with respect to the following performance indicator objectives. A complete list of regulation amendments can be found on the NRC website at the following address: https://scp.nrc.gov/regtoolbox.html.

  • The Agreement State program does not create conflicts, duplications, gaps, or other conditions that jeopardize an orderly pattern in the regulation of radioactive materials under the Atomic Energy Act of 1954, as amended.
  • Regulations adopted by the Agreement State for purposes of compatibility or health and safety were adopted no later than 3 years after the effective date of the NRC regulation.
  • Other program elements, as defined in SA-200 that have been designated as necessary for maintenance of an adequate and compatible program, have been adopted and implemented within 6 months of NRC designation.
  • The State statutes authorize the State to establish a program for the regulation of

[STATE or NRC] Draft IMPEP Report Page 16

agreement material and provide authority for the assumption of regulatory responsibility under the agreement.

  • The State is authorized through its legal authority to license, inspect, and enforce legally binding requirements such as regulations and licenses.
  • Sunset requirements, if any, do not negatively impact the effectiveness of the States regulations.
b. Discussion

The [STATE]s current effective statutory authority is contained in the [LIST REGULATORY AUTHORITY/REGULATIONS], of the [STATE] Statutes. The [Department, Bureau, Program] is designated as the States radiation control agency. [No or list # of legislative amendments] legislation affecting the radiation control program was passed during the review period. [If legislation was passed, mention the impact it has on the program.]

[STATE]s administrative rulemaking process takes approximately [#] months from drafting to finalizing a rule. The public, NRC, other agencies, and potentially impacted licensees and registrants are offered an opportunity to comment during the process. Comments were considered and incorporated, as appropriate, before the regulations we re finalized and approved by the [insert appropriate reference]. The team noted that the States rules and regulations [were/ were not] subject to sunset laws [If they are, explain the process].

During the review period, [STATE] submitted [#] proposed regulation amendment(s), [#] final regulation amendment(s), and [#] legally binding requirements or license condition(s) to the NRC for a compatibility review. [# or None] of the amendments were overdue for State adoption at the time of submission.

At the time of this review, the following [#] amendments were overdue: [OR no amendments were overdue. ] 

* [Example] Exemptions from Licensing, General Licenses, and Distribution of Byproduct Material; Licensing and Reporting Requirements, 10 CFR Parts 30, 31, 32, and 150 amendment (72 FR 58473), that was due for Agreement State adoption by December 17, 2010.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

c. Evaluation

[STATE or NRC] Draft IMPEP Report Page 17

[If there were no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE] met the performance indicator objectives listed in Section 4.1.a. Based on the criteria in MD 5.6, the team recommends that [STATE]s performance with respect to the indicator, Legislation, Regulations, and Other Program Elements, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[If there were performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE] met the performance indicator objectives listed in Section 4.1.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the State/NRC program did not meet indicating how the State/NRC program was deficient. For example:

Regulations adopted by the Agreement State for purposes of compatibility or health and safety were adopted later than 3 years after the effective date of the NRC regulation.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE]s performance with respect to the indicator, Legislation, Regulations, and Other Program Elements, be found [satisfactory, satisfactory, but needs improvement OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

4.2 Sealed Source and Device (SS&D) Evaluation Program

Adequate technical evaluations of SS&D designs are essential to ensure that SS&Ds will maintain their integrity and that the design is adequate to protect public health and safety. NUREG-1556, Volume 3, Consolidated Guidance about Materials Licenses: Applications for Sealed Source and Device Evaluation and Registration, provides information on conducting the SS&D reviews and establishes useful guidance for teams. In accordance with MD 5.6, three sub-elements: Technical Staffing and Training, Technical Quality of the Product Evaluation Program, and Evaluation of Defects and Incidents Regarding SS&Ds, are evaluated to determine if the SS&D program is satisfactory. Agreement States with authority for SS&D [STATE or NRC] Draft IMPEP Report Page 18

evaluation programs who are not performing SS&D reviews are required to commit in writing to having an SS&D evaluation program in place before performing evaluations.

a. Scope

The team used the guidance in SA-108, Reviewing the Non-Common Performance Indicator: Sealed Source and Device Evaluation Program, and evaluated [STATE/COMMONWEALTH/the NRC]s performance with respect to the following performance indicator objectives:

Technical Staffing and Training

  • A well-conceived and balanced staffing strategy has been implemented throughout the review period.
  • Qualification criteria for new technical staff are established and are being followed or qualification criteria will be established if new staff members are hired.
  • Any vacancies, especially senior-level positions, are filled in a timely manner.
  • Management is committed to training and staff qualification.
  • Individuals performing SS&D evaluation activities are adequately qualified and trained to perform their duties.
  • SS&D reviewers are trained and qualified in a reasonable period of time.

Technical Quality of the Product Evaluation Program

  • SS&D evaluations are adequate, accurate, complete, clear, specific, and consistent with the guidance in NUREG-1556, Volume 3.

Evaluation of Defects and Incidents

  • SS&D incidents are reviewed to identify possible manufacturing defects and the root causes of these incidents.
  • Incidents are evaluated to determine if other products may be affected by similar problems. Appropriate action and notifications to the NRC, Agreement States, and others, as appropriate, occur in a timely manner.
b. Discussion

Technical Staffing and Training

[STATE/ COMMONWEALTH/NRC] has [#] staff qualified to perform SS&D reviews [if any are currently being trained mention that as well]. Currently, there were [# or no] vacancies. During the review period [#] of the SS&D staff members left the program and [#] staff members were hired. The positions were vacant from [X to X (days, weeks, months, etc.) give the range of time, e.g., 6 to 9 months]. The [STATE/COMMONWEALTH/NRC] (does/does not have) a training program equivalent to NRC training requirements listed in the NRCs IMC 1248, Appendix D. Add a sentence about refresher training.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.] [STATE or NRC] Draft IMPEP Report Page 19

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of the Product Evaluation

[STATE/COMMONWEALTH/ NRC] has [#] SS&D licensees. The team evaluated [x of y] SS&D actions processed during the review period. These actions included [amendments, new applications, inactivations, etc.]. [Discuss technical performance issues that were found during the review in the Evaluation section]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Evaluation of Defects and Incidents Regarding SS&Ds

The team evaluated [# of #] incidents involving SS&D registered products during the review period. [None or # ] of the incidents were related to manufacturing or design of the sources/devices manufactured or distributed by a licensee with a SS&D registered by [STATE/ COMMONWEALTH/NRC].

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

c. Evaluation

[If there were no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met [STATE or NRC] Draft IMPEP Report Page 20

the performance indicator objectives listed in Section 4.2.a. Based on the criteria in MD 5.6, the team recommends that [STATE/COMMONWEALTH/NRC]s performance with respect to the indicator, Sealed Source and Device Evaluation Program, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[If there were performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/COMMONWEALTH/NRC] met the performance indicator objectives listed in Section 4.2.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the STATE/NRC program did not meet phrased to indicate how the STATE/NRC program was deficient. For example: SS&D evaluations are not adequate, accurate, complete, clear, specific, and consistent with the guidance in NUREG-1556, Volume 3.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/ COMMONWEALTH/NRC]s performance with respect to the indicator, Sealed Source and Device Evaluation Program, be found [satisfactory, satisfactory, but needs improvement, OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

4.3 LLRW Disposal Program

The objective is to determine if [STATE] LLRW disposal program is adequate to protect public health and safety, and the environment. Five sub-elements are used to make this determination: (1) Technical Staffing and Training; (2) Status of LLRW Inspection Program; (3) Technical Quality of Inspections; (4) Technical Quality of Licensing Actions; and (5) Technical Quality of Incident and Allegation Activities.

a. Scope

The team used the guidance in SA-109, Reviewing the Non-Common Performance Indicator: Low-Level Radioactive Waste Disposal Program, and evaluated [STATE] s performance with respect to the following performance indicator objectives:

[STATE or NRC] Draft IMPEP Report Page 21

Technical Staffing and Training

  • Qualified and trained technical staff are available to license, regulate, control, inspect, and assess the operation and performance of the LLRW disposal facility.
  • Qualification criteria for new LLRW technical staff are established and are followed or qualification criteria will be established if new staff members are hired.
  • Any vacancies, especially senior-level positions, are filled in a timely manner.
  • There is a balance in staffing the LLRW licensing and inspection programs.
  • Management is committed to training and staff qualification.
  • Individuals performing LLRW licensing and inspection activities are adequately qualified and trained to perform their duties.
  • LLRW license reviewers and inspectors are trained and qualified in a reasonable period of time.

Status of LLRW Inspection Program

  • The LLRW facility is inspected at prescribed frequencies.
  • Statistical data on the status of the inspection program are maintained and can be retrieved.
  • Deviations from inspection schedules are coordinated between LLRW technical staff and management.
  • There is a plan to perform any overdue inspections and reschedule any missed or deferred inspections; or a basis has been established for not performing any overdue inspections or rescheduling any missed or deferred inspections.
  • Inspection findings are communicated to licensees in a timely manner.

Technical Quality of Inspections

  • Inspections of LLRW licensed activities focus on health, safety, and security.
  • Inspection findings are well-founded and properly documented in reports.
  • Management promptly reviews inspection results.
  • Procedures are in place and used to help identify root causes and poor licensee performance.
  • Inspections address previously identified open items, non-compliances, and violations.
  • Inspection findings lead to appropriate and prompt regulatory action.
  • Supervisors, or senior staff as appropriate, conduct annual accompaniments of each LLRW inspector to assess performance and assure consistent application of inspection policies.
  • Inspection guides are consistent with NRC guidance.
  • An adequate supply of calibrated survey instruments is available to support the inspection program.

Technical Quality of Licensing Actions

  • Licensing action reviews are thorough, complete, consistent, and of acceptable technical quality with health, safety, and security issues properly addressed.
  • Applicable LLRW guidance documents are available to reviewers and are followed.
  • Essential elements of license applications have been submitted and elements are consistent with current NRC or Agreement State regulatory guidance for describing the isotopes and quantities used, qualifications of authorized users, facilities, equipment, locations of use, operating and emergency procedures, and any other requirements necessary to ensure an adequate basis for the licensing action.

[STATE or NRC] Draft IMPEP Report Page 22

  • LLRW license reviewers, if applicable, have the proper signature authority for the cases they review independently.
  • License tie-down conditions are stated clearly and can be inspected.
  • Deficiency letters clearly state regulatory positions and are used at the proper time.
  • Reviews of renewal applications demonstrate a thorough analysis of a licensees inspection and enforcement history.
  • Licensing practices for risk-significant radioactive materials are appropriately implemented including fingerprinting orders (10 CFR Part 37 equivalent).
  • Documents containing sensitive security information are properly marked, handled, controlled, and secured.

Technical Quality of Incident and Allegation Activities

  • LLRW incident response, and allegation procedures are in place and followed.
  • Response actions are appropriate, well-coordinated, and timely.
  • On-site responses are performed when incidents have potential health, safety or security significance.
  • Appropriate follow-up actions are taken to ensure prompt compliance by licensees.
  • Follow-up inspections are scheduled and completed, as necessary.
  • Notifications are made to the NRC Headquarters Operations Center for incidents requiring a 24-hour or immediate notification to the Agreement State or NRC.
  • Incidents are reported to the NMED and closed when required information is obtained.
  • Allegations are investigated in a prompt, appropriate manner.
  • Concerned individuals are notified of investigation conclusions.
  • Concerned individuals identities are protected, as allowed by law.
b. Discussion

[If appropriate, provide a brief summary of the LLRW facilities in the State.]

[If the LLRW facility does not warrant a review, include the following statement: In accordance with SA-109, Reviewing the Non -Common Performance Indicator, Low-Level Radioactive Waste Disposal Program, the team leader in coordination with NRC headquarters management and the Regional Agreement State Officer determined that this indicator did not need to be reviewed during this review period because there were no changes or issues in the closure phase and status of [Name of LLRW disposal site] since the last IMPEP review that would impact safety. Note: if using the previous paragraph, then the following sub-elements may be deleted. ]

[If the State entered into the Agreement prior to 1981 and has authority for LLRW but does not have a facility use the paragraph below]

In 1981, the NRC amended its Policy Statement, Criteria for Guidance of States and NRC in Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through Agreement, to allow a State to seek an amendment for the regulation of LLRW as a separate category. Those States with existing Agreements prior to 1981 were determined to have continued LLRW disposal authority without the need for an amendment. Although, the [STATE/COMMONWEALT] has authority to regulate a LLRW disposal facility, the NRC has not required States to have a program for licensing a disposal facility until such time as the State has been designated as a host State for a LLRW disposal facility. When an Agreement State has been notified or becomes aware of the need to regulate a LLRW disposal facility, it is expected to put in place a regulatory program that will meet the criteria [STATE or NRC] Draft IMPEP Report Page 23

for an adequate and compatible LLRW disposal program. There we re no plans for a LLRW disposal facility in [STATE/COMMONWEALT]. Accordingly, the team did not review this indicator. Note: if using the previous paragraph, then the following sub-elements may be deleted.]

Technical Staffing and Training

[STATE] has [#] qualified LLRW staff [if any are currently being trained mention that as well]. There are [# or no] vacancies at the time of the review. During the review period [#] of the staff members left the LLRW program and [#] staff members were hired. The positions were vacant from [DATE to DATE (days, weeks, months, etc.) give the range of time, (e.g., 6 to 9 months)]. The [STATE] s training program was or was not equivalent to NRC training requirements listed in the NRCs IMC 1248, Appendix E.

[Add details addressing noteworthy aspects of the program (i.e., things the STATE does particularly well).]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Status of LLRW Disposal Inspection Program

[STATE] performed [#] inspections during the review period. The review determined that [STATE] completed the LLRW inspections in accordance with the NRCs inspection frequency [If not, explain in the Evaluation section below].

Inspection findings for the LLRW disposal program were communicated by formal correspondence to the licensee within [#] days following the inspection [If > 30 days, or 45 for a team inspection, explain in Evaluation section below].

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue. Put the percentage of overdue inspections in context.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Inspections

On [DATE], the team accompanied [#] inspectors at the [Name] facility. Under the LLRW license, [e.g., site security, pre-operational environmental monitoring, and facility posting] [STATE or NRC] Draft IMPEP Report Page 24

were observed. Provide summary of inspector accompaniments: The team determined that the inspectors performances observed during the inspector accompaniments indicated that the inspectors were knowledgeable of the requirements for each license type and were able to identify potential health, safety, and security concerns.

The team evaluated [#] inspection files which included waste acceptance, hydrogeological, radiological, security, and environmental hazards, and determined that the inspection reports were thorough, complete, consistent, and had sufficient documentation to ensure that licensee performance with respect to health, safety and security was acceptable. The findings were well-founded, supported by regulations, and were appropriately documented. [If not, explain in the Evaluation section below]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Licensing Actions

[STATE] completed [#] licensing actions during the review period. The team examined [# of 

#] LLRW licensing actions which included [#] new applications, [#] amendments, [#]

renewals, [#] financial assurance, and [#] terminations.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Incident and Allegation Activities

The team evaluated [# of #] incidents and [# of #] allegations during the review period, including [#] referred by the NRC involving the [STATE] LLRW program. [STATE] [has/does not have] written procedures for the handling, review, analysis, response and follow-up of incidents and allegations.

When notified of an incident, management determines the appropriate level of response, which ranges from an immediate response to an in-office review or follow-up during the next routine inspection. Those determinations are made based on both the circumstances and the health and safety significance of the incident. The team found that [STATE]s [STATE or NRC] Draft IMPEP Report Page 25

evaluation of incident notifications and its response to those incidents was thorough, well balanced, complete, and comprehensive.

The team also evaluated [STATE]s reporting of incidents to the NRCs Headquarters Operations Officer (HOO). The team noted that for each incident requiring HOO notification, [STATE] reported the incidents within the required time frame. The team identified [#] incidents that had not been completed and closed in the NRCs NMED including [#] incident with a request for additional information. The team spoke with staff about these events and the staff immediately took action to complete and close the events and provide the additional information as requested.

During the review period, [#] allegations were received and [#] were referred by the NRC. The team evaluated [#] allegations. The team found that staff took prompt and appropriate action in response to each of the concerns raised. The team determined that all allegations reviewed were appropriately closed, concerned individuals were notified timely of the actions taken, and concerned individual s identities were protected whenever possible in accordance with State law. No impacts related to the pandemic were noted in this indicator.

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

c. Evaluation

[If there were no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE] met the performance indicator objectives listed in Section 4.3.a. Based on the criteria in MD 5.6, the team recommends that [STATE]s performance with respect to the indicator, Low-Level Radioactive Waste Disposal Program, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[If there were performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE] met the performance indicator objectives listed in Section 4.3.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the State/NRC program did not meet phrased to indicate how the State/NRC program was deficient. For

[STATE or NRC] Draft IMPEP Report Page 26

example: Inspection findings are not well-founded or properly documented in reports.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE, and the current status of the performance issue.]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE ]s performance with respect to the indicator, Low-Level Radioactive Waste Disposal Program, be found [satisfactory, satisfactory, but needs improvement OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

4.4 UR Program

The objective is to determine if [STATEs/ the NRCs] UR Program is adequate to protect public health and safety, and the environment. Five sub-elements are used to make this determination: (1) Technical Staffing and Training; (2) Status of UR Inspection Program; (3) Technical Quality of Inspections; (4) Technical Quality of Licensing Actions; and (5) Technical Quality of Incident and Allegation Activities.

a. Scope

The team used the guidance in SA-110, Reviewing the Non-Common Performance Indicator: Uranium Recovery Program, and evaluated [STATE/NRC] s performance with respect to the following performance indicator objectives:

Technical Staffing and Training

  • Qualified and trained technical staff are available to license, regulate, control, inspect, and assess the operation and performance of the UR program.
  • Qualification criteria for new UR technical staff are established and are being followed or qualification criteria will be established if new staff members are hired.
  • Any vacancies, especially senior-level positions, are filled in a timely manner.
  • There is a balance in staffing the UR licensing and inspection programs.
  • Management is committed to training and staff qualification.
  • Individuals performing UR licensing and inspection activities are adequately qualified and trained to perform their duties.
  • UR license reviewers and inspectors are trained and qualified in a reasonable period of time.

Status of UR Inspection Program [STATE or NRC] Draft IMPEP Report Page 27

  • The UR facility is inspected at prescribed frequencies.
  • Statistical data on the status of the inspection program are maintained and can be retrieved.
  • Deviations from inspection schedules are coordinated between UR technical staff and management.
  • There is a plan to perform any overdue inspections and reschedule any missed or deferred inspections; or a basis has been established for not performing overdue inspections or rescheduling any missed or deferred inspections.
  • Inspection findings are communicated to licensees in a timely manner.

Technical Quality of Inspections

  • Inspections of UR licensed activities focus on health, safety, and security.
  • Inspection findings are well-founded and properly documented in reports.
  • Management promptly reviews inspection results.
  • Procedures are in place and used to help identify root causes and poor licensee performance.
  • Inspections address previously identified open items, non-compliance, and violations.
  • Inspection findings lead to appropriate and prompt regulatory action.
  • Supervisors, or senior staff as appropriate, conduct annual accompaniments of each UR inspector to assess performance and assure consistent application of inspection policies.
  • Inspection guides are consistent with NRC guidance.
  • An adequate supply of calibrated survey instruments is available to support the inspection program.

Technical Quality of Licensing Actions

  • Licensing action reviews are thorough, complete, consistent, and of acceptable technical quality with health, safety, and security issues properly addressed.
  • Applicable UR guidance documents are available to reviewers and are followed.
  • Essential elements of license applications have been submitted and meet current NRC or Agreement State regulatory guidance (e.g., financial assurance, etc.)
  • UR license reviewers, if applicable, have the proper signature authority for the cases they review independently.
  • License conditions are stated clearly and can be inspected.
  • Deficiency letters clearly state regulatory positions and are used at the proper time.
  • Reviews of renewal applications demonstrate a thorough analysis of a licensees inspection and enforcement history.
  • Licensing practices for risk-significant radioactive materials are appropriately implemented including fingerprinting orders (10 CFR Part 37 equivalent).
  • Documents containing sensitive security information are properly marked, handled, controlled, and secured.

Technical Quality of Incident and Allegation Activities

  • UR incident response, investigation, and allegation procedures are in place and followed.
  • Response actions are appropriate, well-coordinated, and timely.
  • On-site responses are performed when incidents have potential health, safety, or security significance.

[STATE or NRC] Draft IMPEP Report Page 28

  • Appropriate follow-up actions are taken to ensure prompt compliance by licensees.
  • Follow-up inspections are scheduled and completed, as necessary.
  • Notifications are made to the NRC Headquarters Operations Center for incidents requiring a 24-hour or immediate notification to the Agreement State or the NRC.
  • Incidents are reported to the NMED and closed when required information is obtained.
  • Allegations are investigated in a prompt, appropriate manner.
  • Concerned individuals are notified of investigation conclusions.
  • Concerned individuals identities are protected, as allowed by law.
b. Discussion

At the time of the IMPEP review, [STATE/NRC] s UR program consisted of [#] conventional mill licenses, ([#] sites currently under decommissioning and currently undergoing groundwater assessments), [#] in-situ recovery licenses (two licensees in decommissioning status, [#] licensee in standby status, [#] licensee in active production, and [#] licensee newly approved but not in operation), [#] in-situ recovery applications for new facilities, and [#] reclamation licensee to administer cleanup of vicinity properties abutting an in-situ recovery licensee that had been revoked by the [STATE/NRC]. The duties and responsibilities for the [STATE/NRC] UR program has been assigned to staff within the [appropriate organization].

Technical Staffing and Training

[STATE/The NRC] has [#] qualified UR staff [if any are currently being trained mention that as well]. There were [# or no] vacancies at the time of the review. During the review period, [#] of the staff members left the UR program and [#] staff members were hired. The positions were vacant from [# to # (days, weeks, months, etc.) give the range of time, e.g., 6 to 9 months]. [STATE] s training program was or was not equivalent to NRC training requirements listed in the NRCs IMC 1248. Add sentence about refresher training.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Status of the UR Inspection Program

[STATE/The NRC] performed [#] inspections during the review period. The review determined that [STATE/the NRC] completed the UR inspections in accordance with the frequency in IMC 2801, Uranium Mill and 11e.(2) Byproduct Material Disposal Site and Facility Inspection Program [If not, explain in the Evaluation section below]

Inspection findings for the UR disposal program were communicated by formal correspondence to the licensee within [#] days following the inspection. [If > 30 days, or 45 days for a team inspection, explain in Evaluation section below]

[STATE or NRC] Draft IMPEP Report Page 29

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue. Put the percentage of overdue inspections in context.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Inspections

On [DATE], the team accompanied [#] inspectors at the [Name] facility. Under the UR license, [site security, pre-operational environmental monitoring, and facility posting] were observed. The team observed inspectors as they performed inspections related to radiation safety, radiation postings, ALARA, and the Ground Water Quality Discharge Permit. The review found each of the inspectors to be well-trained, prepared for their inspections, and thorough in their reviews. Documentation reviewed was thorough and complete.

The team evaluated [#] inspection files which included radiological, industrial, and chemical hazards, environmental monitoring, effluents, etc. The team determined that the inspection reports were thorough, complete, consistent, and had sufficient documentation to ensure that licensee performance with respect to health, safety and security was acceptable. The findings were well-founded, supported by regulations, and were appropriately documented.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Licensing Actions

For the conventional mills, the licensing actions consisted of [license renewal, annual financial assurance updates, compliance monitoring, and post-decommissioning monitoring for groundwater compliance] for this review period.

For in-situ recovery facilities, the licensing actions consisted of [reviews of new applications, license renewals, license amendments, annual financial updates, decommissioning plans, and project area authorizations] for this review period.

The [STATE/NRC] completed [#] licensing actions during the review period. The team examined [# of #] UR licensing actions which included [#] new applications, [#] [STATE or NRC] Draft IMPEP Report Page 30

amendments, [#] renewals, [#] financial assurance, and [#] terminations. The team found that [STATE]s evaluation of licensing actions and license conditions were thorough, complete, consistent, and of acceptable technical quality with health, safety, and security issues properly addressed.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

Technical Quality of Incident and Allegation Activities

The team evaluated [# of #] incidents and [# of #] allegations involving the [STATE/NRC] UR program. [STATE] /The NRC [had /did not have] written procedures for the handling, review, analysis, response and follow-up of incidents and allegations.

When notified of an incident, management determines the appropriate level of response, which ranges from an immediate response to an in-office review or follow-up during the next routine inspection. Those determinations are made based on both the circumstances and the health and safety significance of the incident. The team found that [STATE]s evaluation of incident notifications and its response to those incidents was thorough, well balanced, complete, and comprehensive.

The team also evaluated [STATE]s reporting of incidents to the NRCs Headquarters Operations Officer (HOO). The team noted that for each incident requiring HOO notification, [STATE] reported the incidents within the required time frame. The team identified [#] incidents that had not been completed and closed in the NRCs NMED including [#] incident with a request for additional information. The team spoke with staff about these events and the staff immediately took action to complete and close the events and provide the additional information as requested.

During the review period, [#] allegations were received and [#] were referred by the NRC. The team evaluated [#] allegations. The team found that staff took prompt and appropriate action in response to each of the concerns raised. The team determined that all allegations reviewed were appropriately closed, concerned individuals were notified timely of the actions taken, and concerned individual s identities were protected whenever possible in accordance with State law. No impacts related to the pandemic were noted in this indicator.

[Discussion section may also include trends, references to periodic meetings, retrospective/prospective outlook, and possible concerns that need to be monitored by the RSAO/next team.]

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[Add details addressing which performance objective above had issues, how it [STATE or NRC] Draft IMPEP Report Page 31

impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[Discuss previous recommendations and the corrective actions taken by the STATE.]

[List any good practices identified by the team. See list of good practices for examples at: https://www.nrc.gov/materials/toolboxes/impep/team-leader.html]

c. Evaluation

[If there were no performance issues, then use the following statement.]

The team determined that, during the review period, [STATE/the NRC] met the performance indicator objectives listed in Section 4.4.a. Based on the criteria in MD 5.6, the team recommends that [STATE/NRC]s performance with respect to the indicator, UR Program, be found satisfactory.

[Add details addressing noteworthy aspects of the program, i.e., things the STATE/NRC does particularly well.]

[If there were performance issues, then use the following statement, as appropriate.]

The team determined that, during the review period, [STATE/the NRC] met the performance indicator objectives listed in Section 4.4.a, except for: 

* [Provide a bulleted list of the performance indicator(s) the State did not meet phrased to indicate how the State was deficient. For example: License conditions are not stated clearly and cannot be inspected.]

[Add a high-level summary addressing which performance objective(s) above had issues, how it impacted the program/health/safety, corrective actions taken by the STATE/NRC, and the current status of the performance issue.]

[If there are performance problems, then explain how the team used MD 5.6 criteria to determine the final rating for this indicator. This explanation would only be necessary for those times where the result is not obvious, or the STATE is on the borderline between two ratings.]

[Evaluate the status of any past recommendation(s) and briefly outline the teams basis for closing or leaving the recommendation open, consistent with the discussion in Section 2.0, above.]

Based on the IMPEP evaluation criteria in MD 5.6, the team recommends that [STATE/NRC]s performance with respect to the indicator, UR P rogram, be found [satisfactory, satisfactory, but needs improvement OR unsatisfactory]. Add reference to new and old recommendations?

d. MRB Discussion and Chairs Determination

The final report will present the MRB Chairs determination regarding this indicator.

5.0

SUMMARY

[STATE or NRC] Draft IMPEP Report Page 32

The team found [STATE/NRC program] s performance to be satisfactory for [all OR the following [number/all] performance indicator(s): [Select from this LIST: Technical Staffing and Training; Status of Materials Inspection Program; Technical Quality of Inspections; Technical Quality of Licensing Actions; Technical Quality of Incident and Allegation Activities; Legislation, Regulations, and Other Program Elements; Sealed Source and Device Evaluation Program; Low-Level Radioactive Waste Disposal Program; and UR Program. [For the NRC review: use commas to separate the performance indicators.)) performance indicator(s)]. The team also found [STATE/NRC program]s performance to be [ satisfactory but needs improvement or unsatisfactory] for the following [number] performance indicators: [LIST INDICATORS].

[INSERT OTHER NOTABLE FINDINGS: e.g., The finding for the Legislation, Regulations, and Other Program Elements performance indicator remains unchanged from the previous IMPEP review. [OR] Progress has been made on the indicator [NAME], but the State has not yet addressed (#) outstanding NRC comments regarding earlier regulation packages. [OR] (#) regulation amendments were overdue for adoption by the State, etc.].

The team [did not make any new recommendations OR made [#] new recommendations and] determined that the recommendation(s) from the [YEAR] IMPEP review should be closed and/or, believe that the previous recommendation(s) [regarding (e.g., regulation adoption/document security markings/development and implementation of a formal training program/etc.) should remain open] OR [there were no recommendations from the previous review for the team to consider]. List each recommendation here.

[INSERT OTHER NOTABLE FINDINGS, e.g., The team recommends monitoring, heightened oversight, etc. Outline the reason the team is making the recommendation.] [e.g.,]. Due to continued improved performance, the team recommends that the period of [HEIGHTENED OVERSIGHT or MONITORING] be discontinued. In making this recommendation, the team considered that [STATE] had improved ratings in [#] out of the [#] performance indicators found less than satisfactory during the [YEAR] IMPEP review. OR other bases for removing or placing the [STATE] on a period of Heightened Oversight or Monitoring.]

Accordingly, the team recommends that the [STATE/NRC] radiation control program be found [adequate to protect public health and safety/adequate to protect public health and safety but needs improvement, or not adequate to protect public health and safety] and [compatible/not compatible] with the NRC's program. The team recommends that a periodic meeting take place in approximately [#] years with the next IMPEP review taking place in approximately [#] years. [Further, the team recommended that the period of [HEIGHTENED OVESIGHT or MONITORING] be [IMPOSED or TERMINATED)) LIST OF APPENDICES

Appendix A IMPEP Review Team Members

Appendix B Inspector Accompaniments

APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Areas of Responsibility

Name, Organization Team Leader Technical Staffing and Training Inspector Accompaniments

Name, Organization Team Leader in Training Status of Materials Inspection Program

Name, Organization Technical Quality of Inspections Inspector Accompaniments

Name, Organization Technical Quality of Licensing Actions

Name, Organization Technical Quality of Incident and Allegation Activities

Name, Organization Legislation, Regulations, and Other Program Elements

Add the following non-common performance indicators, as applicable:

Name, Organization Sealed Source and Device Evaluation Program

Name, Organization Low-Level Radioactive Waste Disposal Program

Name, Organization Uranium Recovery Program APPENDIX B

INSPECTOR ACCOMPANIMENTS

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

Accompaniment No.: 1 License No.: License Type: e.g., Industrial Radiography Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 2 License No. : License Type : e.g., Medical Institution Broad Scope Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 3 License No. : License Type : e.g., Panoramic Irradiator Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 4 License No. : License Type : e.g., Manufacturing and Distribution Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 5 License No. : License Type : e.g., Industrial Radiography Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 6 License No. : License Type : e.g., LLRW Priority: Inspection Date: xx/xx/xx Inspectors initials:

Accompaniment No. : 7 License No. : License Type : e.g., Uranium Recovery Priority: Inspection Date: xx/xx/xx Inspectors initials:}}

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