at http://www.nrc.gov/NRC/IM/87112.html
..
Audits -
The frequency and scope of audits of the licensed program will vary. However,
note that at a minimum, licensees are required by 10 CFR 20.1101(c) to
review the radiation safety program content and implementation at least
annually. Additionally, irradiator licensees are required, by 10 CFR
36.51, to perform annual reviews for irradiator operators and evaluate
the safety performance of each irradiator operator. The results of audits
should be documented. Examine these records with particular attention
to deficiencies identified by the auditors, and note any
corrective actions taken as a result of deficiencies found.
If no corrective actions were taken, determine why the licensee disregarded
deficiencies identified during audits, and whether the lack of corrective
actions caused the licensee to be in non-compliance with regulatory requirements.
I would think this would carry over to non-irradiator licenses as well - If the log date is missing, and reported so during an audit, then some corrective action must take place - if an entry is required then the log must be corrected to reflect this, even if the date is after the due date - in addition some explanation of this correction must be given, the most logical place would be at the site of the missing date, and there's no time like the present to correct an non-compliance issue - with initials or signature.
I use your method as well - If I find missing lab inspections for a period - I recommend (tell) lab personnel or PIs to conduct their inspection, and log it in with the current date, and an explanation that the inspection is late and should have been conducted earlier on the specified date required. I have them sign or initial this for the record. I feel that an inspector coming to audit my license will feel better if a corrective action was taken on site and recorded so officially for the record.
Not sure if this helps or is applicable.
Steve Hand
Radiation Safety
University of Maryland
Tad Blanchard wrote:
During a recent audit, I noted that a date had not been entered into a
chronological log that included weekly inspections.I asked the individual who had made the entry to enter the date he
performed the inspection and place his initials next to the entry. This
was noted on the audit report.His supervisor has asked that I provide a "reference" as to where it is
"legal" to correct a record in this fashion.Can anyone give me a reference (i.e., 10CFR??) that I can provide to the
supervisor. I believe I have seen this in an NRC notice somewhere but I
can recall.Thanks all. Please email me direct or post to RADSAFE if you feel this may
be pertinent to others.Tad Blanchard NASA-Goddard Space Flight Center
Sr Health Physics Tech Code 205.9, Greenbelt, MD 20771
Parallax, Inc Phone: 301-286-9157
A Member of the OHI Team Fax: 301-286-1618
mailto:tmblanch@pop200.gsfc.nasa.gov
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