SOW Radiation Safety Officer_Updated 2026 .docx

STATEMENT OF WORK (SOW)

1. Contract Title: Radiation Safety Officer

2. General Information:

This is a non-personnel services contract to provide Radiation Safety Officer (RSO) services at John D. Dingell VA Medical Center located in Detroit, MI. The Government shall not exercise any supervision or control over the contract service providers performing the service herein. Such contract service providers shall be accountable solely to the contractor, who in turn is responsible to the Government.

3. Background:

This is a non-personnel services contract to provide Radiation Safety Officer (RSO) services at John D. Dingell VA Medical Center located in Detroit, MI. The Government shall not exercise any supervision or control over the contract service providers performing the service herein. Such contract service providers shall be accountable solely to the contractor, who in turn is responsible to the Government.

4. Scope:

The Radiation Safety Program which is required for the John D Dingell VA Medical Center must have a Radiation Safety Officer (RSO) to oversee the safe use of radiation at the medical center as required by 10 CFR 35.24(b) (http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/part035-0024.html). The RSO must meet certain criteria to be named on the hospital’s radioactive material license. The criteria include experience in a similar position and/or having been named an RSO on another similar license (medical-use radioactive license). The purpose of this contract is to provide tasks as required of a RSO in administering a broad scope of the use of radioactive materials per: The National Health Physics Program (NHPP) (http://www.patientcare.va.gov/NHPP.asp). The RSO must also be approved to be named on the permit by the NHPP.

This program provides regulatory oversight for the Nuclear Regulatory Commission master materials license issued to VHA to include permitting for use of materials, on-site inspections, and investigations of allegations, medical events, and incidents. The contractor shall comply with applicable Federal, State, and local laws, regulations, codes, technical manuals, and recommendations, and acceptable commercial practices in the delivery of required services.

5. Specific Tasks:

a. The RSO is responsible for managing the Radiation Protection Program

b. Identifying radiation protection problems

c. Initiating recommending, or providing corrective actions

d. Verifying implementation of corrective actions and stopping unsafe activities

6. Performance Monitoring (if applicable):

a. The contractor shall report to the Medical Facility Director and the Medical Center Safety Office. In the usual organizational arrangements, the Radiation Safety Officer completes day-to-day actions with oversight by the Radiation Safety Committee. Overall, the actions by the Radiation Safety Committee and Radiation Safety Officer must include, but not be limited to:

i. Providing oversight for the safe use of radioactive materials with a focus to ensure occupational and public doses are as low as reasonably achievable (ALARA) and a safety conscious work environment is achieved.

ii. Establishing committee membership to include the Radiation Safety Officer, a management representative, and a representative for each type of authorized use and a representative from Nursing Service.

iii. Holding meetings at intervals not to exceed 6 calendar months; and establishing a committee quorum of at least one-half of committee membership for meetings which must include the Radiation Safety Officer and management representative.

iv. Preparing records and reporting committee results as required by executive management and/or Title 10 Code of Federal Regulations (CFR), Part 35; and ensuring the records document executive management approvals for actions under 10 CFR 35 (e.g., 35.24 and 35.26).

v. Coordinating with other medical facility committees as needed and reporting results of committee meetings to executive management or other medical facility oversight committees.

vi. Attending the Laser Safety Committee (semi-annual), Health and Safety Committee (monthly), and the MRI committee (Quarterly).

b. The contractor shall complete and provide oversight for the radiation program through periodic reviews and audits, to include:

i. Annual radiation safety program review per 10 CFR 20.1101, to include locations of use.

ii. Reviews audits as needed based on the radioactive materials scope of use.

iii. Evaluation of results from audits, reviews and inspections to determine possible generic issues or trends. Identify root causes, specify corrective actions and actions to prevent recurrence, and determine if any results are applicable to other uses of radioactive materials.

iv. Distribution of results of audits, reviews and inspections to all work centers and availability to the staff working with or around radioactive materials.

v. Oversight and follow-up to resolve health and safety issues and radiation safety program deviations as needed.

vi. Reviewing, at least every 6 months, occupational and public doses.

vii. Reviewing, at least every 6 months, any identified health and safety issues or possible radiation safety program deviations from regulatory compliance or required practices.

viii. Conduct quarterly Nuclear Medicine Department audits.

ix. Reviewing and approving training and experience for prospective Radiation Safety Officers, authorized users and other staff requiring regulatory approval.

x. Reviewing and approving proposed changes to training, equipment, facilities and radiation safety procedures or practices.

xi. Providing training as required to fluoroscope users.

xii. Contractor shall conduct inspections and calibrations on all x-ray equipment are made at least annually and after the equipment has been repaired or modified in any way that might affect output.

c. The contractor shall ensure that sealed source inventories are completed:

i. Quarterly, for sealed sources with either current activity greater than one millicurie or current activity greater than 1000 times the quantities in 10 CFR 20, Appendix C.

ii. Semiannually, for all other sealed sources except sources specifically exempted by 10 CFR 30.

iii. Shall ensure that sealed source records are maintained for transfer or disposition to document leak test results, if the sealed source was required by regulation or permit condition to have a leak test.

iv. Shall provide results if requested, for sealed source inventories and leak tests to NHPP.

d. The contractor shall provide oversight for security of radioactive materials by:

i. Compliance with regulations per 10 CFR 20.1801, 10 CFR 20.1802 and 10 CFR 37 (when issued).

ii. Prevention of adversary or unauthorized removal of radioactive materials.

iii. Compliance with the security guidelines in VHA Handbook 1200.06.

iv. Focusing on adequate security commensurate with possible risks of radioactive materials unauthorized use.

v. Classifying sealed sources, not in active use for their intended clinical or research purpose for a period of 24 months, as disused sources and evaluating the disused sources for disposal as expeditiously as possible.

vi. Using NRC documents (NUREG-1556 series) as guidance to prepare and submit requests for new, renewed, or amended permits.

vii. Restricting radiation safety program implementation to be consistent with the program codes (i.e., whether broad-scope or limited-scope medical or research uses) and permitting conditions approved for the permittee.

viii. Ensuring approvals for authorized users and locations of use (except as authorized per 10 CFR 35.14) are limited to broad-scope permittees.

e. The contractor shall ensure compliance with posting requirements per 10 CFR 19 and 10 CFR 21.6, as in the following:

i. VHA Radioactive Material Permit No. 21-04234-01 issued under VHA NRC License No. 03-23853-01VA authorizes the use of radioactive materials at this location. Contact Jeremy Mangum at jeremy.mangum@va.gov or (702) 355-6201 to examine the permit and supporting documents.

ii. VHA license, amendments, and supporting application are available for examination by contacting NHPP at 501-257-1571, or at mailing address NHPP (115HP/NLR), Bldg 101, Room 208, 2200 Fort Roots Drive, North Little Rock, AR 72114.

f. Providing information to workers at the various locations of use or work centers, especially satellite locations of use, on current radiation safety program and regulatory issues, as needed, using NHPP Intranet Web site, periodic newsletters, and other information resources made available to permittees.

g. Perform annual physics evaluations using American College of Radiology (ACR) standards and phantoms on all equipment listed within each section as outlined in Appendix A. Provide certifications for each piece of equipment that can be displayed and presented during audits or inspections.

h. Ensure all x-ray producing equipment is inspected for safety operations, compliance with applicable FDA performance and safety standards and compliance with other accepted standards, including the Joint Commission, and standards established by the medical center for quality performance and quality control.

i. Perform annual evaluations and calibration and calibration accuracy tests of nuclear medicine equipment including scintillation cameras, thyroid update systems, probe/well counters, dose calibrators, and survey meters.

j. Shall work to ensure that any plan affecting the use of space or function adjacent to areas and within areas approved for radioactive material use, sources of ionizing radiation use, or ionizing radiation machine use is assessed to meet regulatory requirements and referred to the Radiation Safety Committee for review and approval prior to any move or alteration of that space.

k. Shall provide structural shielding design reports for linear accelerators to NHP for approval prior to installation and shielding reports prior to first clinical use.

l. Manage waste disposal for all users of radioactivity

m. Prepare all license renewals and amendments

n. Provide the following additional services:

i. Instruction, upon request, of personnel as required by state, federal, and accreditation agencies if performed in conjunction with quarterly audits;

ii. A review of incidents involving licensed material with respect to cause and subsequent actions taken and prepare incident reports;

iii. Preparation of misadministration/medical event reports

iv. Be reachable in person or by telephone for emergency situations

v. Be available for inspections in person for planned inspections, by phone/internet for unannounced inspections.

7. Security Requirements:

The contractor employees shall not have access to VA sensitive or computer information and will not require routine access to VA Facilities. The contractor employees’ shall require intermittent access only and will be escorted by VA employees while at VA Facilities. No background investigation is required.

A flash badge shall be obtained from the facility HR office. The flash badge will be worn while the Contractor employee(s) is on-site and will be returned to the HR office, upon completion of that job.

8. Government-Furnished Equipment (GFE)/Government-Furnished Information (GFI):

N/A

9. Qualifications:

a. The Contractor shall be approved by the VA National Health Physics Program (NHHP) to act as the RSO for the John D Dingell VA Medical Center radioactive materials permit.

b. The Contractor shall meet qualifications in order to be able to be named on the materials permit at the John D Dingell VA Medical Center and be authorized users for all materials permitted by: 10 CFR 35.100, 10 CFR 35.200, 10 CFR 35.300 and Research. The RSO must be experienced with administering radioactive materials to patients and would have to be able to meet qualifications per 10 CFR Part 35.50 and 10 CFR Part 35.59.

c. The Contractor shall dress professionally at all times in no less than business casual and carry out all interactions with the utmost professionalism.

d. The Contractor shall be aware of other departments at the John D Dingell VA Medical Center.

e. The Contractor assigned to perform services covered by this contract shall be a United States Citizen.

f. The Contractor shall follow all local, state, and federal regulations involving oversight of the Radiation Safety Program at the John D Dingell VA Medical Center.

10. Period of Performance:

The Government anticipates awarding a firm-fixed-priced service contract. The period of performance shall be for a base year plus four (4) one-year option periods.

11. Place of Performance:

John D Dingell VA Medical Center 4646 John R Street Detroit, MI 48183

Pontiac CBOC – X ray Room 44200 Woodward Avenue, Suite 212 Pontiac, MI 48341

12. Hours of Operation:

The contractor shall provide oversight of the John D Dingell VA Medical Center Imaging department for the safe use of radioactive materials, between the hours of 7:00 AM through 4:30 PM, Monday through Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The contractor must at all times maintain an adequate workforce for the performance of all tasks defined within this SOW when the Government facility is not closed for the above reasons. When hiring personnel, the contractor shall keep in mind that the stability and continuity of the workforce are essential. The RSO will be reachable both though telecommunications and the Internet during normal business hours of operation at the facility. The RSO will be available onsite within a reasonable amount of time for Emergencies as per regulatory policy, such as accidental Exposure to Radioactive Material and accidental spills.