Radiation Safety UPPS No. 04.05.07
Issue No. 5
Effective Date: 07/15/2009
Review: October 1 E4Y
01. POLICY STATEMENTS
01.01 Because of university radiation usage, it is necessary to employ proper procedures in the purchase, use, storage, and disposal of radioactive materials and radiation emitting devices.
01.02 Texas State will use radiation and radioactive materials according to the Radiation Control Act and the Texas Department of State Health Services (DSHS) regulations contained in Title 25, Texas Administrative Code (TAC), Section 289, and pursuant to a current Radioactive Material License (RAML) or Certificate of Registration (COR). Individuals can access these regulations via the Texas DSHS http://www.dshs.state.tx.us/radiation/rules.shtm.
01.03 Environmental Health, Safety and Risk Management has primary responsibility and authority for assuring that the university complies with all applicable regulations and policies associated with radiation.
01.04 Policies and procedures related to radioactive materials and devices are in the Texas State Radiation Safety Manual.
02. RADIATION SAFETY COMMITTEE
02.01 A Radiation Safety Committee (RSC) will annually review and monitor university use of radioactive materials and radiation emitting devices. This committee appointed by the president, reports directly to the president. RSC responsibilities will conform with 25 TAC §289.
02.02 The RSC consists of a chair; the university radiation safety officer (RSO); representatives from each department that utilizes or handles radioactive materials or radiation devices; the medical director of the Student Health Center; the director of Purchasing; the director of Materials Management; the director of Environmental, Health, Safety and Risk Management; and additional members who are experienced in dealing with radioactive materials, ionizing or non-ionizing radiation.
02.03 Members of the RSC are appointed in the following manner:
a. By June 15 of each year, the dean of the College of Science will submit to the president via the vice president for Academic Affairs recommendations for:
1) A qualified person to serve as chair of the RSC for the succeeding academic year
2) The university Radiation Safety Office for the COR and RAML
3) Committee members
b. By August l, the president will appoint the committee or request additional nominees from the dean of the College of Science.
02.04 The RSC meets each long semester and at such other times as deemed necessary by the chair.
03. UNIVERSITY RADIATION SAFETY OFFICER
03.01 The university RSO acts under the delegated authority of the university president and the Radiation Safety Committee in the daily implementation of policies and procedures regarding the safe use of radioisotopes and sources of radiation. The RSO shall:
a. Ensure that each user of radioisotopes or radiation sources is in compliance with Texas Regulations for Control of Radiation, Texas DSHS, with regard to the posting of notices to workers, receiving and opening of packages containing radioisotopes, storage and use of radioisotopes, surveys of work areas, storage and disposal of radioactive wastes, maintenance of records, and authorship and revisions of the radiation safety procedures in the Texas State Radiation Safety Manual.
b. Obtain permission to perform leak tests of sealed sources and conduct such tests as required in the Texas Regulations for the Control of Radiation.
c. Maintain records required by the Texas Regulations for the Control of Radiation. Each licensee will provide this information at intervals not to exceed six months.
d. Stop any operations not in compliance with the above Texas Regulations or with the Texas State Radiation Safety Manual until the individual has corrected the violation.
e. Oversee proper registration of all radiation devices and supervise the radiation safety officers who hold licenses for x-ray generating equipment as required by Texas DSHS.
03.02 The university RSO may delegate certain radiation safety duties to other regular university employees in departments with special needs (such as the College of Science and the Student Health Center).
03.03 The university RSO and designee are authorized to immediately stop any operation that may compromise health and safety at the university or which may result in a breach of any local, state, or federal environmental health and safety regulation.
03.04 The university RSO must meet the training and experience as specified by 25 TAC §289 and guidelines issued by the Texas DSHS, Bureau of Radiation Control. The university shall pay the license renewal fee.
04. PROCEDURES FOR USE, PROCUREMENT, RECEIPT AND STORAGE OF RADIOACTIVE MATERIALS
04.01 An individual must hold a license or the university must list their name as an authorized user on the university’s license and, prior to procurement of radioactive materials or devices, must contact the university RSO for proper authorization and briefing on controls and regulations. The authorized users will assure that all workers and students under their responsibility follow safe and proper procedures.
04.02 The ordering department must submit orders for radioactive materials to the university RSO prior to order placement. The ordering department must coordinate with the university RSO to identify the radioactive material delivery area.
04.03 When shipments of radioactive materials are received, the unopened package will be delivered to the proper authorized user. Upon receipt of the radioactive materials, the university RSO will inventory the shipment to determine the type of radioisotope, chemical form of the radioisotope, and quantity in µCi or mCi.
04.04 Users may store radioactive materials containers emitting no more than two milli-Roentgens per hour in their laboratories. Users must store materials emitting more than two milli-Roentgens per hour in a locked facility shielded to reduce radiation to no more than two milli-Roentgens per hour at the surface. The university will provide and the university RSO must approve the storage facility.
04.05 Because of federal and state regulations regarding radioactive materials procurement, ordering departments must make all such purchases via purchase order. Use of procurement cards (P-cards) to purchase radioactive materials is strictly prohibited.
05. PROCEDURES FOR USE, PROCUREMENT, RECEIPT AND STORAGE OF X-RAY GENERATING EQUIPMENT
05.01 The university Radiation Safety Committee must approve all persons who use x-ray generating equipment with x-rays emitted purposely or unintentionally from non-radioactive devices requiring registration by the Texas DSHS (including equipment such as x-ray diffraction equipment, medical or dental x-ray equipment, etc.). The authorized user will assure that all supervised personnel follow safe and proper procedures. The university RSO will coordinate proper maintenance related to x-ray safety (particularly x-ray safety interlocks and shielding) to assure authorized personnel perform the maintenance at appropriate intervals.
05.02 The authorized user must contact the university RSO prior to procurement by purchase order, transfer from another institution, loan or donation of x-ray generating equipment with x-rays emitted from non-radioactive sources. Proper authorization and briefing on controls and regulations by the university RSO must precede the procurement of any x-ray generating equipment.
05.03 The proper licensee must receive the shipment of x-ray generating equipment unassembled and oversee unpacking and installing the equipment to assure that it does not leak x-ray radiation during installation and operation in excess of amounts exempted by the Texas DSHS. The user will notify the university RSO in advance of all x-ray generating equipment brought or delivered to campus.
05.04 The user must notify the university RSO immediately of x-ray equipment safety interlock or shielding failures. The RSO must formally approve repairs to affected x-ray equipment. X-ray equipment storage must assure that intentional or accidental unauthorized equipment operation is not reasonably possible. The university RSO must review the status of any stored x-ray producing equipment.
06. PROCEDURES FOR DISPOSAL OF RADIOACTIVE MATERIALS
06.01 The disposal of radioactive materials is strictly controlled by federal and state regulations. In order to assure compliance with these regulations, the user should dispose of radioactive materials only after consultation with the university RSO.
06.02 General guidelines for the disposal of radioactive materials are contained in the Texas State Radiation Safety Manual.
07. PROCEDURES FOR DISPOSAL OF X-RAY GENERATING EQUIPMENT
07.01 The disposal or transfer of x-ray generating equipment from non-radioactive sources is strictly controlled by federal and state regulations. In order to assure compliance with these regulations, the user should dispose of or transfer x-ray equipment only after consultation with the university RSO.
07.02 Texas DSHS provides general guidelines for the disposal of x-ray generating equipment from non-radioactive sources.
08. EMERGENCY ACTION PROCEDURES
08.01 Specific recommended actions for emergencies are given in the Texas State Radiation Safety Manual.
08.02 For further emergency aid, contact one of the following:
University Radiation Safety Officer
Environmental Health, Safety and Risk Management Office
Terry A. Dowdy
Director, Environmental Health, Safety &Risk Management
09. REVIEWERS OF THIS UPPS
09.01 Reviewers of this UPPS include the following:
University Radiation Safety Officer October 1 E4Y
Director, Environmental Health, October 1 E4Y
Safety & Risk Management
Dean, College of Science October 1 E4Y
Associate Vice President for Research October 1 E4Y
10. CERTIFICATION STATEMENT
This UPPS has been approved by the following individuals in their official capacities and represents Texas State policy and procedure from the date of this document until superseded.
University Radiation Safety Officer; senior reviewer of this UPPS
Director, Environmental Health, Safety & Risk Management
Vice President for Finance and Support Services