36C24420Q1126 0001 - amendment to RFQ - answer Questions- 02.pdf

5. PROJECT NUMBER (if applicable)

CODE 7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO. 1. CONTRACT ID CODE

FACILITY CODE CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30 PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

1 20

0001 460-21-1-132-0002 0

00244

Department of Veterans Affairs Network Contracting Office 4

00244

Department of Veterans Affairs Network Contracting Office 4

To all Offerors/Bidders 36C24420Q1126

X x 1

Answers provided for three (3) questions received, see page 2

Update to the SOW is provided with a highlighted area -See section: I. SCOPE OF WORK, based on the questions received.

Additionally, no additional line items will be included for badge management.

The requirement for badge management falls under the duties of the RSO. The updated SOW will show two highlighted areas pertaining to RSO duties, which includes badge management. See section: U. RADIATION SAFETY OFFICER (RSO) DUTIES AND

RESPONSIBILITIES

10-14-2020

Question 1:

Is this estimate (150 badges) a total number of dosimeters (“Whole Body” dosimeters + “Extremity” dosimeters)?

Answer: Yes, this is the total number including whole body and extremity.

Question 2:

Are these estimated 150 dosimeters to be exchanged Monthly?

Answer: Yes, on-average potentially 150 exchanged on a monthly basis

Question 3:

Is Neutron detection required

Answer: No

STATEMENT OF WORK

Health Physicist and Radiation Safety Officer (RSO) Services

I. SCOPE OF WORK:

Health Physicist services for routine inspection and performance testing of all radiological equipment including annual lead inspection, review and interpretation data from various dosimetry devices. Act as the point person for Radiology safety meetings.

Health Physicist must be close enough for recall in the event of radiological event occurs and must be able to respond within 4 business hours of notification.

This is to include the monthly processing and delivery of an average of 150 badges for personnel radiation monitoring - badges are to be exchanged monthly. The 150 badges are estimated to be in the following categories: 90% badges, 5% wrist badges and 5% ring badges. Monthly monitoring of radiation exposure and badge usage reports will be provided on monthly bases to Wilmington VA Medical Center (VAMC) Department of Radiology and the Radiation Safety Officer. Thermoluminescence dosimeters (TLD) or Optically Stimulated Luminescence (OSL) badges are preferred. Vendor must have software that allows for efficient tracking of personnel radiation monitoring devices and provide a monthly report that clearly states the employee radiation exposure level.

The contractor shall furnish all labor, equipment, transportation and parts necessary to provide Radiation Protection Survey Services and Health Physics Survey Services at both the Wilmington VAMC, 1601 Kirkwood Highway, Wilmington, Delaware 19805 and Georgetown Community Based Outpatient Clinic (CBOC) at 21748 Roth Ave, Georgetown DE 19947, in accordance with the Schedule of Services and Prices. The contractor shall provide access to a database that allows for efficient tracking of these personnel radiation monitoring devices each month and provide a monthly report with web-based access so real time access can be accomplished at the Wilmington VAMC in case mail delivery is slow. Badges shall not use photographic film but use optically stimulated luminescence (OSL) technology which provides greater sensitivity and a wider dynamic range. The OSL technology permits multiple readouts to confirm reported radiation does. Other dosimeters can only be analyzed once and film cannot be redeveloped to correct for processing errors. Monitor badges must identify whether exposure is static or dynamic and offer a higher degree of stability than badges using photographic film.

The contractor’s duties and responsibilities include ensuring radiological safety and compliance with federal, state regulations, conditions/ limitations of the facility's X-ray Registration & Radioactive Materials Licenses and TJC requirements

II. QUALIFICATIONS:

A. The contractor must have an established business, with an office and fulltime staff to include a "fully qualified" physicist/radiation safety officer.

B. “Fully Qualified" is based upon training and on experience in the field. For training, the FSE(s) must be a qualified radiation physicist/radiation safety officer which is defined as an individual who is certified by the American Board of Radiology (ABR) in the appropriate disciplines of radiological physics including diagnostic, therapeutic and medical nuclear physics or who demonstrates equivalent competency in the disciplines.

For field experience, the physicist/radiation safety officer has a minimum of two years’ experience with respect to performing radiation protection survey services.

C. The physicist/radiation safety officer shall be authorized by the contractor to perform the radiation protection survey services. “Fully Qualified” competent physicist/radiation safety officer shall perform all work. The contractor shall provide certification by the American Board of Radiology (ABR) of the physicist to perform the work for each appropriate discipline of radiology physics including diagnostic, therapeutic and medical nuclear physics or submit written documentation which demonstrates equivalent competency in the disciplines. The Contracting Officer (CO) may authenticate the training requirements, request training certificates or credentials from the contractor at any time for any personnel who are servicing or installing any VA equipment. The CO and/or VA technical point of contact (POC) specifically reserves the right to reject any of the contractor's personnel and refuse them permission to work on the VA equipment.

D. If subcontractors are used, they must be approved in advance by the CO. The contractor shall submit any proposed change in subcontractor(s) to the CO for approval/disapproval.

III. SERVICES TO BE PROVIDED:

A. GENERAL CONDITIONS:

Contract for Radiation Protection Survey requirements of JCAH Standard i.e., (I) Policies/Procedures Review, (II) PT Dose Measurements (A) and (B), (III) Equipment performance and (IV) Quality Control.

Examine personnel monitoring records to determine the adequacy of reporting and compliance with state and federal regulations. Examine for adequate use of warning labels and signs, review written safety procedures, examine devices and techniques used in patient and operator protection from scattered and primary radiation and evaluate radiation levels in uncontrolled areas and calculate their acceptability with respect to regulatory specifications.

1. Contractor must have software that will accurately track the badge usage and provide a monthly report that is provided to the Department of Radiology, Wilmington

VAMC.

2. Badges should not use photographic film.

3. Monitor badges must identify whether exposure is static or dynamic.

4. Individual monthly monitoring is required with prompt delivery of badges and timely reports of findings sent to the Department of Radiology, Wilmington VAMC, Radiation Safety Officer by the 10th of each month.

5. A fee will be allowed for lost badges equal to the cost of the lost badge.

6. A fee will be allowed for badges that are shipped using standard postage separately.

B. PATIENT DOSE MEASUREMENTS:

A qualified individual will monitor doses from each radiology procedure in each x-ray room.

Each radiographic room would require an average of 15 procedure calculations for entrance skin exposure. There is to be a quantitative value for the dose being given to patients for each procedure. Compliance with this standard requires that radiographic exposure measurements be made in each x-ray room at a variety of KVp settings. For manual radiographic techniques (know KVp & mAs) the patient exposure will be computed by the physicist for the commonly employed examinations in that room. For photo-timed techniques, the MAs value delivered in a radiograph may be available, otherwise the physicist will make measurements using a phantom to characterize the photo-time response. A qualified individual will review and sign quarterly dosimetry reports generated by the dosimetry vendor. The contractor will identify those staff that who have exceeded “As Low As Reasonably Achievable” (ALARA) ALARA I or ALARA II and recommend ways to reduce radiation exposure to those staff members in the future.

Perform x-ray shielding recommendations up to one (1) room each contract year at no additional fee as part of our routine services. Shielding recommendations in excess of this amount will be assessed a professional fee. Shielding recommendation reports will require a minimum of ten (10) business days to complete.

Perform one (1) internal dose estimate each contract year at no additional fee above our contracted fee structure. Dose estimates in excess of this amount will be billed separately. Dose estimation reports will require a minimum of ten (10) business days to complete. On an annual basis, review the department's radiation safety policies and procedures in accordance with standards set forth by federal, state and local regulations, as well as recommendations of the Joint Commission. Assistance will be provided in the development of written procedures.

C. EMPLOYEE OCCUPATIONAL EXPOSURE:

A qualified individual will review and sign quarterly dosimetry reports generated by the dosimetry vendor. The contractor will identify those staff that who have exceeded ALARA I or ALARA II and recommend ways to reduce radiation exposure to those staff members in the future. On a monthly basis, provide the number of P whole body badges and S ring badges, in accordance with federal and state requirements.

Monthly dosimetry reports will be reviewed closely by a health physicist/diagnostic medical physicist for any overexposure or unusual trends and to assess whether radiation exposure levels are ALARA and below regulatory limits. Administrative dose assignments will be made for badges that have been lost or damaged.

Provide Multiple Employer Total Exposure Reports (Meter Program) on a monthly basis.

On an annual basis, provide up to the number of Badge Summaries, as noted on Schedule A, in accordance with federal and state requirements at the amount outlined on Schedule A. The fees for any additional annual film badge summary reports will be billed at a rate outlined on Schedule B.

D. EQUIPMENT PERFORMANCE:

Equipment performance is defined as performance with respect to the image quality produced as well as radiation safety and compliance with state and/or federal regulations. The annual physics report will include, as a minimum, high-contrast and low-contrast resolution tests for fluoroscopic systems as well as radiation outputs for a standard patient thickness in the automatic brightness mode, and cins dose rate for cardiac systems, intrinsic uniformity, intrinsic or special resolution, sensitivity, energy resolution, count rate parameters, formatter or video display, system interlocks and overall system performance. For a radiographic system, KVp accuracy, timer accuracy and MA linearity will be included as a bare minimum and focal spot size measurements will be performed. These will be evaluated at or above standards set forth through the American College of Radiologists (ACR), Nuclear Regulatory Commission (NRC), VA National Health Physics Program (NHPP) and the Joint Commission (JC).

E. NUCLEAR MEDICINE EQUIPMENT:

Semi-annual quality assurance (QA) testing will be performed on all nuclear medicine equipment. The QA testing will be in compliance with the ACR and NHPP directives.

The Nuclear Medicine service at Wilmington VAMC is not currently ACR accredited but seek accreditation in the future. The contractor will review all records to verify compliance with federal and state regulatory bodies.

F. RADIOGRAPHIC EQUIPMENT:

The survey criteria are those of the National Council on Radiation Protection, Report No.

102, "Medical X-ray and Gamma Ray Protection for Energies Up to 50 MeV"; Report No.

105, "Radiation Protection for Medical and Allied Health Personnel"; Report No. 147, "Structural Shielding Design and Evaluation for Medical X-Ray Imaging Facilities, and applicable State regulations.

PROGRAM DESIGN:

Contractor will survey radiographic units as follows:

• A visual inspection of the room/unit insuring that applicable warning labels and caution signs are present and a determination of proper function of all radiographic control devices.

• SID measurement versus indicated SID distance.

• Alignment of the X-ray field versus the visual field.

• Measurement of X-ray field versus indicated field.

• Measure of alignment between center of the X-ray field and center of image receptor/light field.

• Measurement of illuminance of light localizer.

• Automatic collimation accuracy determination if applicable.

• Evaluation of timer accuracy and reproducibility if applicable.

• Evaluation of exposure reproducibility.

• kVp evaluation.

• Radiation output measurements at kVp ranges used clinically.

• Beam filtration (Half Value Layer).

• Determination of mA station linearity.

If elected, will also evaluate the following for direct capture digital radiographic units:

High-contrast Resolution

Low-contrast Resolution

Dynamic range of System

Evaluation of fluoroscopic equipment will include:

• A visual inspection of the room/unit ensuring that applicable warning labels and caution signs are present and a determination of proper function of all fluoroscopic control devices.

• Beam alignment and collimation.

• Evaluation of fluoroscopic interlock system.

• Maximum Exposure Rate in all imaging modes.

• Displayed air-kerma rate and cumulative air kerma accuracy (when applicable).

• High-contrast resolution.

• Low-contrast detectability.

• Beam filtration (Half Value Layer).

• Radiation measurement of primary beam transmission and secondary scatter radiation.

• Evaluation of fluoroscopic field size versus visible area.

• Measurement of fluoroscopic source to skin distance.

A complete written report will be provided for each radiographic/fluoroscopic tube surveyed. The report will reflect items of both compliance and non-compliance in accordance with applicable State and Federal regulations. Vendor Will provide appropriate meters and physics phantoms for testing. We will not provide manufacturer phantom for certain non-standard, specialized manufacturer X-ray uses.

G. FLUOROSCOPIC EQUIPMENT:

Determine the maximum patient entrance exposure rate and evaluate the exposure rate as a function of potential in R/min. Test cumulative timing device for proper operation, measure specific scattered and transmitted radiation levels around intensifier, screen, primary frame and accessory shielding using an appropriate phantom. Measure the operation intercepted scatter at various positions using as appropriate primary barrier.

Measure Source-to-Skin distance. Determine the adequacy of the beam filtration;

examine shielding used for personnel protection during fluoroscopy. Equipment considered "new" under Delaware or Federal regulations all the extra requirements in addition to the above will be checked. All radiographic equipment will be evaluated as above with additional test performed as required by Delaware or Federal regulation.

H. COMPUTERIZED TOMOGRAPHY (CT) SCANNER PERFORMANCE

EVALUATION:

Annually, a qualified medical physicist will perform a performance evaluation of CT scanner. A formal report of these evaluations will be made. The parameters to be examined during the annual performance evaluation will be consistent with the most current ACR Quality Control Manual and The Joint Commission Diagnostic Imaging Standards Elements of Performance requirements, and include the following:

• Protocol Review o Protocol review of Adult Head, Abdomen, and High Resolution Chest o Protocol Review of Pediatric Head, Abdomen (when applicable) o Protocol Review of Brain Perfusion (when applicable)

• Phantom & Scanner Alignment

• Alignment light accuracy

• Scout Prescription accuracy including slice position accuracy

• Table travel accuracy

• Gantry tilt accuracy

• Radiation Beam Width

• CT Number Accuracy & Uniformity

• Low Contrast Performance (including CNR & Low Contrast Resolution)

• Image Uniformity and Noise

• Distance Calibration Accuracy

• Artifact Evaluation

• High Contrast Spatial Resolution

• Image Acquisition Display Monitor Evaluation

• Patient Dosimetry – Measurement of a dosimetry index utilizing the clinical protocol for:

o Adult Head & Adult Abdomen, o Pediatric Head & Pediatric Abdomen (when applicable) o Dose Index Display Verification

(measured CTDIvol to be within 20% of indicated value)

• Review of the routine quality assurance tests being performed by the CT staff.

• Review the results of periodic spot checks that are performed in accordance with CT manufacturer recommendations, State regulations and accreditation body standards.

I. ACR MAMMOGRAPHY ACCREDITATION PROGRAM & MQSA CERTIFICATION

PERFORMANCE EVALUATION:

At this time there is no on-site breast imaging/mammography performed at the Wilmington VAMC.

J. I-131 THYROID QUALITY MANAGEMENT

The contractor will ensure all aspects of I-131 Thyroid Quality Management Program are within compliance standards. Compliance standards will be reviewed quarterly and revised as requirements dictate. The contractor will provide a review summary to the Radiation Safety Committee on a quarterly basis.

K. NUCLEAR MEDICINE POLICY

The contractor will be responsible for reviewing Nuclear Medicine policy and procedure manual to ensure all policies and procedures are up to date and in compliance with current standards. The contractor shall inform the Chief, Radiology, and Nuclear Medicine Provider of any upcoming changes and make recommendations to ensure continued compliance. Policies and procedures will be reviewed at least annually or as changes are published through various regulatory organizations. The contractor will review all pertinent records to verify compliance with the NRC, NHPP and JC on a quarterly basis.

L. ACR NUCLEAR MEDICINE ACCREDITATION PROGRAM & PERFORMANCE

EVALUATION:

At this time, the Nuclear Medicine program is not accredited through the ACR, but reserves the right to seek accreditation in the future.

M. MISCELLANEOUS:

Each nuclear camera within the hospital will be surveyed at least once during the contract year as needed, recommendations will be made for correction of deficiencies and re-surveys of equipment will be performed under the contract to determine if corrective actions taken were properly carried out.

Each tube head with the facility will be surveyed at least once during the contract year as needed. Recommendations will be made for correction of deficiencies and re-surveys of equipment will be performed under the contract to determine if corrective actions taken were properly carried out.

Charges to include one follow-up call per tube head in the event a tube calibration falls out of expected range

Charges to include one follow-up call per nuclear camera.

Follow-up visits to the facility to re-survey any changes, additions, repair or for any other necessary inspections as required by the Chief, Radiology Service as needed.

Report to be submitted to the Chief, Radiology Service within 30 days after each inspection.

I. NUMBER OF NUCLEAR CAMERAS: 2

II. I. NUMBER OF TUBEHEADS: 45

N. TRAINING:

The contractor will conduct radiation safety and radioactive materials training as needed to ensure compliance with NHPP and NRC directives.

P. Schedule for Deliverables

If for any reason any deliverable cannot be delivered within the scheduled time frame, the contractor is required to explain why in writing to the CO, including a firm commitment of when the work shall be completed. This notice shall cite the reasons for the delay. The CO will then review the facts and issue a response in accordance with the applicable regulations.

Q. Changes to Statement of Work (SOW)

Any changes to this SOW shall be authorized and approved only through written correspondence from the CO. A copy of each change will be kept in a project folder along with all other products of the project. Costs incurred by the contractor through the actions of parties other than the CO shall be borne by the contractor.

R. Government Responsibilities

Government will assure that the Radiation Safety Officer or designee distributes all dosimetry badges to appropriate Wilmington VAMC staff, and collects and returns badges to the contractor promptly each month.

S. Confidentiality and Nondisclosure

a. It is agreed that:

1. The preliminary and final deliverables and all associated working papers, application source code, and other material deemed relevant by VA which have been generated by the contractor in the performance of this task order are the exclusive property of the U.S. Government and shall be submitted to the CO at the conclusion of the task order.

2. No information shall be released by the contractor. Any requests for information relating to this task order presented to the contractor shall be submitted to the CO for response.

3. Press releases, marketing material or any other printed or electronic documentation related to this project, shall not be publicized without written approval of the CO.

T. VA HOURS OF OPERATION:

All surveys will be performed during extended VA business hours (8:00 a.m. - 5:00 p.m.)

Monday through Friday, except Federal holidays, unless otherwise specified. Contractor may work outside normal business hours by arrangement with the technical POC if such services are provided without additional charge to the Government.

TEN (10) HOLIDAYS OBSERVED BY THE FEDERAL GOVERNMENT ARE AS

FOLLOWS:

New Year’s Day January 1

Martin Luther King Day 3rd Monday in January

President's Day 3rd Monday in February

Memorial Day Last Monday in May

Independence Day July 4th

Labor Day 1st Monday in September

Columbus Day 2nd Monday in October

Veterans Day November 11

Thanksgiving Last Thursday in November

Christmas December 25

U. RADIATION SAFETY OFFICER (RSO) DUTIES AND RESPONSIBILITIES

Unsafe activities involving licensed material are stopped

• Radiation exposures are ALARA;

• Up-to-date radiation protection procedures in the daily, operation of the licensee's radioactive material program & radiation producing machines are developed, distributed, and implemented;

• Possession, use, and storage of licensed material is consistent with the limitations in the license, the regulations, the SSDR certificate(s), and the manufacturer's recommendations and instructions

• Personnel training is conducted yearly and is commensurate with the individual's duties regarding licensed material

• Documentation is maintained to demonstrate that individuals are not likely to receive, in 1 year, a radiation dose in excess of 10% of the allowable limits or that personnel monitoring devices are provided

• When necessary, personnel monitoring devices are used and exchanged at the proper intervals, and records of the results of such monitoring are maintained

• Licensed material is properly secured

• Documentation is maintained to demonstrate, by measurement or calculation, that the total effective dose equivalent to the individual likely to receive the highest dose from the licensed operation does not exceed the annual limit for members of the public

• Proper authorities are notified of incidents such as loss or theft of licensed material, damage to or malfunction of sealed sources, and fire

• Medical events and precursor events are investigated and reported to appropriate regulatory agencies, cause(s) are identified, and timely corrective action(s) are taken

• Audits of the radiation protection program are performed at least annually and documented

• If violations of regulations, license conditions, or program weaknesses are identified, effective corrective actions are developed, implemented, and documented

• Licensed material is transported, or offered for transport, in accordance with all applicable DOT requirements

• Licensed material is disposed of properly

• Appropriate records are maintained

• An up-to-date license is maintained, and amendment and renewal requests are submitted in a timely manner.

• Annual lead inspection in Hospital and CBOC

• MRI non-ACR Quality Assurance Program

• Report on-site 8 hours per month

• Analysis or distribution film badges and reports

IV. SPECIAL INSTRUCTIONS:

A. Contractor Check-In: The contractor's representative will report to the technical POC, Radiology Service, prior to performance of each survey. On approved overtime, contractor will report to VA Police Dispatch E.R. Lobby.

B. Documentation: At the conclusion of each survey, the contractor shall provide to the technical POC, Radiology Service, and the Radiation Protection Officer, a written, signed and dated report of all measurements taken with indications of meeting the Delaware State and Federal requirements and the Guidelines from the American College of Radiology.

C. Exclusions: Consumable parts and supplies are not covered under this contract.

D. Inspection of Equipment: Any site visits shall be coordinated in advance with technical POC, Radiology Service, (302) 994-2511 extension 4202.

V. WORKMAN'S COMPENSATION:

The contractor agrees to maintain workmen's compensation insurance as may be required by law covering its employees who perform the service.

VI. INVOICES: To be submitted electronically IAW the contract.

VII. QUALITY ASSURANCE SURVEILLANCE PLAN (QASP):

The Contractor shall participate in the quarterly RSC meetings, and provide information and data during these meetings detailing any findings and work performed. The QASP includes the following surveillance by the Government:

Performance Requirement

Acceptable Quality

Level

Surveillance

Method

1. Health

Physicist

Assists in the administration of and decision making for the Radiation Safety Program.

Assists in planning new initiatives, providing health physics surveys, equipment and supply purchases, plan and monitor acquisitions of radioactive material, act as the alternate radiation safety officer. Assists in the analysis of current and past operations to monitor efficiency, gather lessons learned and identify areas in need of improvement and areas of excellence.

100% Periodic

Inspection and

Customer

Complaints

2. Health

Serve as a member of the Wilmington VAMC Radiation Safety Committee.

100% Attendance at all meetings

3. Health Physicist

Review radiological operations within Wilmington VAMC for compliance with regulations and NRC licenses.

100% Periodic inspection and customer complaints

4. Health Physicist

Ensure that radioactive material movements, shipments and receipts are in accordance with 10 CFR 20 and 49 CFR 173.

100% No issues with material movement

5. Health Physicist

Coordinate with appropriate medical activity personnel in the event of a suspected overexposure to ionizing or non-ionizing radiation

100% Periodic inspection of program.

6. Health Physicist

Provide centralized issue, collection, control and submission for processing dosimetry devices

100% Periodic inspection of program.

7. Health

Maintain a formal radioisotope and laser inventory

100% Periodic inspection of program

8. Health Physicist

Maintain exposure records, DD Form 1141, for exposed employees

100% Periodic inspection of program

9. Health Physicist

Ensure radioactive waste is stored, handled, packaged and disposed of IAW NRC and VHA requirements

100% Periodic inspection of program

10.RSO The RSO will oversee the use of all ionizing radiation within the organization to make certain that radiologic services are

100% Periodic inspection and customer complaints provided in accordance with law, regulation, and organizational policy.

11. RSO

Serve as a member of the Wilmington VAMC Radiation Safety Committee.

100% Attendance at all meetings

Equipment List/ Schedule month:

Client Modality Service Name Booking Month

Manufacturer Model

Department of Veterans Affairs - Wilmington

CT CT APT June Philips Ingenuity 64s

Department of Veterans Affairs - Wilmington

MRI MR APT June Siemens Magnetom Avanto 1.5T

Department of Veterans Affairs - Wilmington

Nuclear Medicine

Camera APT May Siemens E-Cam

Department of Veterans Affairs - Wilmington

Nuclear Medicine

Camera APT May Siemens Symbia

Department of Veterans Affairs - Wilmington

Nuclear Medicine

Camera QA (semi-annual)

November Siemens E-Cam

Department of Veterans Affairs - Wilmington

Nuclear Medicine

Camera QA (semi-annual)

November Siemens Symbia

Department of Veterans Affairs - Wilmington

Radiation Protection

Aprons - Annual June

Department of Veterans Affairs - Wilmington

Radiation Protection

RSO Services (monthly)

Monthly

Radiation Protection

RAM Audit NM (quarterly) - Hospital

Quarterly

Radiology X-ray APT - Fluoroscopic tube

February Philips ProxiDiagnost N90

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - CV/IR/EP tube

June Philips Allura XPER FD

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeac ProMax 3D Mid

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dental tube

June Planmeca Prox

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Dexa Tube

June Hologic Horizon

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Fluoroscopic tube

June Phillips RF ProxiDiagnostic N90

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Fluoroscopic tube

June OEC 9900 Elite

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Fluoroscopic tube

June OEC 9900 Elite

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Fluoroscopic tube

June Liebel Flarsheim

Cysto

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Fluoroscopic tube

June OEC 9900 Elite

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June Philips RF ProxiDiagnostic N90

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June Philips R/F

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June GE RadPro

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June Liebel Flarsheim

Cysto

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June

Radiology X-ray APT - Radiographic

RadPro Elite XA

Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June GE Optima

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic

Radiology X-ray APT - Radiographic Tube

June RadPro OMNERA 400A

Department of Veterans Affairs - Wilmington

Radiology X-ray APT - Radiographic Tube

June GE Optima

Department of Veterans Affairs - Georgetown DE (aff.

with VA Wilmington)

Radiology X-ray APT - Radiographic Tube

April Philips Digital Diagnost Eleva

End of Document

PROGRAM DESIGN: