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:
William
Hollingsworth
University
Radiation Safety Officer
Environmental
Health, Safety and Risk Management Office
Phone:
245-3616
Terry
A. Dowdy
Director,
Environmental Health, Safety &Risk Management
Phone:
245-36l6
09. REVIEWERS OF THIS UPPS
09.01 Reviewers
of this UPPS include the following:
Position Date
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
President