TRUST POLICY FOR RADIATION PROTECTION

TRUST POLICY FOR RADIATION PROTECTION Reference Number RKM/2014/039 Version: V2.3 Status: Final Author: S. Evans Job Title: RPA Version / Amendment History Version Date Author Reason 2.0 12/2/2009 S Evans Periodic Review 2.1 26/8/2009 S. Evans Periodic Review 2.2 20.08.12 P. Selmic/ S. Evans Periodic Review 2.3 08/2014 P. Owens/ S Evans Periodic Review Intended Recipients: All Staff who may be exposed to radiation as part of their employment Training and Dissemination: All Divisions To be read in conjunction with: IRMER Policy In consultation with and Date: Health and Safety Committee, Radiation Protection Committee EIRA stage One Completed YES Stage two not required Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Patient Safety Group Date of Issue December 2014 Review Date and Frequency Contact for Review Executive Lead Signature January 2018 then 3 yearly Radiation Protection Advisor Chief Nurse and Director of Patient Experience Radiation Protection Policy - 1 -

Approving Executive Signature Chief Nurse and Director of Patient Experience Contents Page Introduction 3 Purpose and Outcomes 3 Definitions Used 3-4 Key Responsibilities & Duties 4-7 General Requirements for Compliance 7-12 Monitoring Compliance and Effectiveness 12 References 13 Appendices Appendix 1 EIRA 14-18 Radiation Protection Policy - 2 -

POLICY ON RADIATION PROTECTION 1. Introduction The Trust values the benefits, which arise from using radiations for diagnosis and treatment, and is committed to provide these services while following good practices and meeting statutory requirements to minimise risk to patients, staff and visitors. 2. Purpose and Outcomes Derby Hospitals NHS Foundation Trust aims to put measures into place such that ionising radiation doses to all persons are kept as low as is reasonably practicable. Doses to employees over 18 will be restricted so that they do not exceed 6mSv per year effective dose, and do not exceed three tenths of any other dose limit, thus not requiring them to be designated as classified workers. Doses to all persons will be restricted such that the dose to the critical group from any single source of radiation does not exceed 300 Sv per year, as far as is reasonably practicable. Medical exposures of patients will be justified by an authorised IRMER Practitioner such that the benefit of the exposure to the patient will exceed any risk from the radiation dose. Doses to patients will be the minimum required to achieve the intended diagnostic or therapeutic purpose, taking into account the available techniques and equipment. Nonionising radiations will be used such as to minimise any unintended detriment from exposures. Regulations and Requirements to be met: Regulations/Guidance The Ionising Radiations Regulations 1999 (IRR1999) - with supporting Code and Guidance Notes - for the protection of persons during work with ionising radiation. The Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER2000) apply to persons undergoing medical exposures including medico-legal and research The Environmental Permitting Regulations 2010 (EPR2010) apply to the accumulation, use and disposal of radioactive substances The Control of Artificial Optical Radiation at Work Regulations 2010 (AOR2010) apply to the use of laser and ultra violet light for any purpose Guidance on the safe use of lasers, intense light source systems and LEDs in medical, surgical, dental and aesthetic practices (MHRA2008) cover the use of lasers (visible or invisible) and other intense light sources. 3. Definitions Used Ionising radiations occur as: x-rays generated electrically in diagnostic machines for examining patients by fluoroscopy, films or digital images. These are used in the radiology imaging departments, and as mobile sets in wards and theatres. higher energy x-rays produced by a superficial radiotherapy treatment machine very high energy x-rays produced by linear accelerators for radiotherapy electrons produced by an accelerator for radiotherapy radiations from radioactive materials used for diagnosis and therapy in nuclear medicine, and on the oncology ward Radiation Protection Policy - 3 -

Non-ionising radiations occur as: low power lasers used as narrow beams of light to aid alignment of patients or equipment. high power lasers used for therapy in clinics or theatres high power radio-frequency radiations driving treatment accelerators. microwave radiations from MRI scanners and catering cookers. ultra-violet light used for dermatology. 4. Key Responsibilities/Duties 4.1 Director of Nursing The Director of Nursing is the lead executive for the use of radiations within the Trust. The DON will ensure that a suitable Radiation Protection Adviser is consulted as required by the Ionising Radiations Regulations 1999 that permits are held for the use of radioactive materials and the accumulation and disposal or radioactive waste and that written procedures are in place for all medical radiation exposures. There is a need to appoint a Radioactive Waste Adviser. The Director of Nursing is responsible for ensuring the Trust s Chief Executive is informed on all Radiation issues. 4.2 Divisional Management The responsibility for practical implementation of radiation protection requirements is via the Trust line management structure within each Division. Divisional Directors and General Managers must be aware of the requirements within their Division, and must ensure that service managers are aware of local responsibility for implementation that has been delegated to them, and to ensure that appropriate resources are made available. Where work activities encompass staff from more than one Division, there must be cooperation at all levels to ensure that requirements are met. 4.3 General Managers A number of important roles are devolved to Service Managers to carry out on behalf of the employer and various staff are therefore entitled by the Trust to carry these out. These will include: - carrying out of risk assessments - appointment of Radiation Protection Supervisors - consultation with the Radiation Protection Adviser on local matters - accounting for radioactive materials and radioactive waste - reviewing radiation doses to staff - carrying out quality assurance - staff training - assist in the writing and review of local rules Details of individual staff entitlements are contained in their respective job descriptions. Radiation Protection Policy - 4 -

4.4 Radiation Protection Adviser (RPA) Suitable Radiation Protection Advisers must be appointed in writing. The RPA must be provided with adequate information and facilities to perform his functions. The sole function of the Radiation Protection Adviser is to advise the Trust on how to comply with the Ionising Radiations Regulations 1999. The Radiation Protection Adviser must have a certificate of competence from a body approved by the Health and Safety Executive. 4.5 Radioactive Waste Adviser (RWA) A Suitable Radioactive Waste Adviser must be appointed. Suitable Radioactive Waste Advisers must be appointed in writing. The RWA must be provided with adequate information and facilities to perform his/her functions. The sole function of the Radioactive Waste Adviser is to advise the Trust on how to comply with the Environmental Permitting Regulations and Permits the Trust holds. The Radioactive Waste Adviser must have a certificate of competence from a body approved by the Health and Safety Executive. 4.6 Laser Protection Adviser (LPA) The Trust must have access to a suitably qualified Laser Protection Adviser to advise on safety matters with respect to the use of any laser devices. 4.7 Radiation Protection Supervisors (RPS) One or more Radiation Protection Supervisors must be appointed by the relevant general managers wherever a controlled area has been designated under the IRR 1999. The appointment must be in writing and suitable training must be given. The role of the RPS is to help ensure that the requirements of the Local Rules are followed for their area of responsibility, and to report to their manager any deficiencies that occur. 4.8 Medical Physics Experts (MPE) The Trust ensures that sufficient Medical Physics Experts are involved in every medical radiation exposure of patients. An MPE is a science graduate experienced in the application of physics to the diagnostic and/or therapeutic uses of ionising radiation. The role of the MPE includes optimisation of patient exposures, image quality and assessment of patient doses. 4.9 All employees Duties under the IRR 1999: Employees shall not knowingly expose themselves to excessive radiation and shall take reasonable care. Radiation Protection Policy - 5 -

Where PPE is provided, proper use must be made of it, defects must be reported, it must be returned after use. The employee must co-operate with the employer where dose measurements are necessary. Any employee who suspects an overexposure has occurred shall forthwith inform their manager. 4.10 Radiation Protection Committee (RPC) The Radiation Protection Committee consists of managers from principal departments that use radiation and representatives from all clinical divisions. It also includes representatives from other organisations in Southern Derbyshire where there is a need for co-operation of employers under IRR 1999. The committee meets at least bi-monthly and submits reports to the Patient Safety Committee. The RPC will discuss, review and audit radiation protection at an operational level. Reports to other committees will provide assessment of the level of compliance with legislation, as well as detailing of compliance issues and the outcome of incident reports. 4.11 Health and Safety Committee The Health and Safety Committee will receive bi-annual reports from the RPC. The Health and Safety Committee will discuss issues raised by the RPC that have wider H&S implications within the Trust. The committee can allocate resources to address specific issues from a specific budget. 4.12 Patient Safety Committee The Patient Safety Committee will receive bi-annual reports from the RPC. The Patient Safety Committee will deal with radiation protection issues on a more strategic level such as: impact of new legislation, non compliances with legislation, risk to employees as a whole and the general population, and risks to the continuing function of the organisation. The Patient Safety Committee can make recommendations regarding the overall allocation of resources to radiation protection matters and overall Trust policies. 4.13 Women of Childbearing Age Female staff of childbearing age must be aware of the risk from ionising radiations during pregnancy. The radiation dose to the foetus must not exceed 1mSv in the remainder of the declared term of the pregnancy. In most cases, doses of ionising radiations to staff are low and no specific special arrangements are required. However, in the later stages of pregnancy issues such as discomfort in wearing lead-rubber x-ray protective aprons may occur. In such cases, the staff member may wish to avoid some work activities. Department managers will need to discuss any special arrangements on an individual basis with the staff member. Radiation Protection Policy - 6 -

Note that there is no legal requirement for female staff to inform the employer of any pregnancy, but where the staff member chooses not to inform the employer, the Trust is not required to make any special arrangements. The risk to breast feeding mothers resulting from the use of unsealed radioactive materials is very low and no special provisions are required. 5. General requirements for compliance Medical Radiation Exposures The Trust has a Policy for Medical Ionising Radiation Exposures, which describes what must be done in relation to specific work activities. Training general Divisions are required to arrange suitable training for all staff who may be involved with any radiations. This is designed to make them aware of the risks, and how they should protect themselves, and others. Training requirements should be discussed with the Radiation Protection Adviser. The level and detail of training required will vary between staff groups from a simple awareness of radiation warning symbols with explanation of the meaning of controlled areas up to a detailed knowledge of radiation protection. Training is required in the context of EPR 10 and should be discussed with the RWA. Basic training for employees should be refreshed at intervals not exceeding five years. Training Equipment used for medical exposures All staff, including medical staff, who use equipment to give medical exposures to patients from any kind of radiations, must have received adequate practical training in the use of each specific piece of equipment. This may be given by an applications specialist from the equipment supplier, or by a person deemed competent as a trainer by the Trust. Records must be available for inspection by the competent authority which may include the Health and Safety Executive, Department of Health and Environment Agency. Departments need to have procedures in place to ensure that sufficient trained staff are available for each piece of equipment and that trained staff have adequate practical experience to maintain their competence. Training Ionising Radiation (Medical Exposure) Regulations Staff involved in medical exposures of patients as referrers, practitioners and operators under the IRME Regulations must follow the Trust Policy for Medical Radiation Exposures in order to comply with the current legislation and must have been authorised by the Trust to carry out the role. Details of training of IRMER Practitioners and Operators must be recorded by the Divisions/Departments including theoretical and practical training. The exact form of the information recorded will depend on the professional groups involved e.g. a competency matrix. Records must be available on request by the competent authority, including for medical staff. Radiation Protection Policy - 7 -

There is no statutory requirement to repeat or update training, but all IRMER Practitioners and Operators must carry out relevant continuing professional development to ensure that they remain up to date. Departments/Divisions will need to take reasonable steps to ensure that staff with roles defined under IRMER carry out suitable CPD e.g. ensuring staff maintain their professional registration where relevant. Exposure of Persons Undergoing Medical Exposures or Treatment to a Dose of Ionising Radiation Much Greater Than Intended Where it is suspected that a person undergoing medical exposure or treatment has been exposed to a dose of ionising radiation much greater than intended, an investigation will be mounted by the Division or Divisions concerned. The investigation will need to determine whether the incident results from failure of the equipment or any other cause. It will also need to determine whether the incident requires statutory notification to the relevant competent authority according to guidance pertaining at the time of the incident. Where the incident results from a failure of equipment notification would be to the Health and Safety Executive, for other causes, notification would be to the IR(ME)R inspectorate at the Care Quality Commission. From IRR1999: All exposures to ionising radiations must be justified as giving net benefit to the individual or population as a whole, and kept as low as is reasonably practicable, and such that no dose limits are exceeded. These are the fundamental principles of radiation protection. Divisions will ensure that all facilities are designed and constructed based on these principles, in consultation with the RPA. Protection measures will be primarily by design features and engineering controls based on prior risk assessments of practices and facilities carried out in consultation with the Radiation Protection Adviser. Where it is necessary for persons to enter radiation areas, suitable working arrangements and personal protective equipment (PPE) will be provided in consultation with the Radiation Protection Adviser. PPE must be adequate and suitable. Training all staff who are likely to be exposed to radiation as part of their work must have suitable training in radiation protection. All staff must be aware of the ionising radiation warning symbol and be able to understand any warning notices. Prior authorisation all practices involving the use of ionising radiations carried out by the Trust have been previously authorised by and notified to the Health and Safety Executive. A list of authorised practices is available from the HSE or the RPA. Risk assessments must be carried out prior to the commencement of any practice or construction/alteration of an area involving the use of ionising radiations. These assessments will be used to resolve what protection measures are required such that doses of radiation to all persons are kept as low as is reasonably practicable. Divisions are required to carry out suitable and sufficient radiation risk assessments in consultation with the Radiation Protection Adviser. Review of risk assessments is required after commencement of use of facilities or practices and at intervals of not more than three years thereafter. Generic risk assessments may be used where equipment and conditions of use are similar. Radiation dose monitoring is required in controlled areas and to assess personal doses to staff who may receive doses of radiation as a result of their work activities. Radiation Protection Policy - 8 -

Environmental dose surveys will be carried out as necessary on new or modified facilities in conjunction with the Radiation Protection Adviser. Members of staff who are likely to receive more than 1mSv radiation dose in one year will normally be issued with a personal dosemeter. Where individual parts of the body may receive a significant dose (normally greater than one tenth of any dose limit), other dosemeters may be issued to assess the dose in relation to dose limits for individual organs or tissues. The nature and extent of dose monitoring in areas will be specified by the Radiation Protection Adviser. Where dosemeters are not routinely issued, dosemeters may be issued for set periods, or to a representative sample of staff, to demonstrate that doses are being kept as low as reasonably practicable and do not require staff to be designated as classified workers. Where a member of staff believes they have received an accidental dose of radiation or whose radiation dosemeter has been accidentally irradiated must inform their manager immediately and make arrangements for their monitor to be read out and exchanged for a replacement. Investigation level: Where any person who wears a radiation dosemeter exceeds 1mSv effective dose, or more than the period proportion of three tenths of the dose limit for any other organ/tissue for a single monitoring period, an investigation will be carried out in consultation with the Radiation Protection Adviser to establish whether the dose is real, and what measures need to be taken to prevent a re-occurrence of the incident. The Radiation Protection Adviser will determine if the incident needs to be notified to the HSE. Departmental managers should review dose reports and query any unusual doses, even if the investigation level is not exceeded to help ensure that doses are kept as low as is reasonably practicable. Outside Workers: Where any outside worker, who is designated as a classified worker under IRR99 works in a controlled area on DHFT premises, a suitable dose estimate will be provided by the department, using appropriate methods, to be entered into their passbook. Controlled Areas are demarcated spaces, which must be designated by the employer, in consultation with the Radiation Protection Adviser, according to Regulations, where a significant risk of exposure to ionising radiations is identified by suitable risk assessments. Entry is allowed only when written working arrangements are followed. Local Rules Divisions will ensure that every department that has one or more controlled areas will draw up suitable working arrangements in consultation with the Radiation Protection Adviser; these working arrangements will be written into Local Rules for that area. The local rules will contain: the name of the Employer, Radiation Protection Adviser and Radiation Protection Supervisors, a list of controlled areas, the working arrangements and contingency plans in the event of a foreseen incident and the dose investigation levels. Relevant working arrangements will be displayed in each controlled area (or in the case of mobile radiography equipment, on the equipment). Divisions must ensure that staff who are routinely involved in work with ionising radiations in areas for which they have responsibility read the local rules that apply to that work, and keep a record of the names of staff who have read the rules. Radiation Protection Policy - 9 -

Contingency Plans contained in the Local Rules must be sufficiently detailed to cover all foreseen incidents, each type of equipment, and must be rehearsed by staff at intervals not exceeding five years/ Radiation Protection Supervisors (RPS) are appointed in writing by the Division from those working in each area where one or more radiation controlled area exists. The appointment letter must detail the areas and staff groups for whom they are responsible, especially where staff from more than one Division are involved in the work activity. They have daily oversight of working practices to help ensure compliance with Local Rules. All RPSs must receive suitable training to carry out their duties. The Radiation Protection Adviser will advise on the nature of the training required. Training must be refreshed at intervals not exceeding five years. Radiation Protection Advisers and Non Ionising Advisers are experts in particular applications of radiation and lasers, whose appointments are notified to the Health and Safety Executive, and must be consulted by the employer as defined in the Regulations. They visit departments to which their advice relates, and help prepare suitable protective measures in consultation with heads and senior staff in the departments. for ionising radiation - Simon Evans for non-ionising radiation Simon Evans for Radioactive Waste Dudley Ibbett (Radioactive materials) Radiation Protection Advisers must be suitable for their expected role, having relevant experience in medical uses of radiation. Detailed requirements are contained in the person specification for the role. From IR(ME)R 2000 (Amended 2006/2011): The employer carries the legal responsibility for compliance with these Regulations. The Trust recognises that ionising radiations from medical exposures form the largest proportion of man made exposures to the population and therefore has a duty to ensure that doses of radiation from medical exposures are clinically justified and kept as low as is reasonably practicable. The Referrer will be a Registered health professional, authorised by the employer. The referrer must supply appropriate clinical information about the patient to support the request for an exposure. Referrers do not need specific training under the regulations. Non medically qualified referrers will need sufficient knowledge to assess the clinical indicators in the light of referral criteria and be authorised to refer patients as required. Practitioner means a suitably trained, registered health professional who is entitled by the employer to take responsibility for an individual medical exposure. The role of the IR(ME)R Practitioner is to justify each individual medical exposure. In some cases, being able to justify a procedure medically will enable a person to justify the radiation exposure. Operator means any person, authorised by the employer, who carries out any practical aspect of the procedure of a medical exposure, and are personally responsible for that aspect. Radiation Protection Policy - 10 -

Practical Aspects means the physical conduct of any medical exposure, and any supporting aspects, including the handling and use of radiological equipment, the assessment of technical and physical parameters including radiation doses, calibration and maintenance of equipment, preparation and administration of radioactive medicinal products, and the reporting of images. Adequate Training Practitioners and Operators are expected to have acquired knowledge of radiation use and radiation protection appropriate to their activities in accordance with IRMER Regulation 11(1), and as indicated in Schedule 2 of the Regulations. IRMER Policy: The Trust IRMER Policy gives more detail on compliance with the IRME Regulations. Persons Authorised to Act as Referrer, Practitioner and Operator, along with a broad outline of the scope of their authorisation is appended to the IRMER Policy. From EPR 2010 (Amended 2012): Registration; A list is kept of radioactive materials and their maximum quantities previously registered with the Environment Agency. No person may purchase or acquire by any other means, any radioactive materials without the consent of the Radiation Protection Adviser, or the Head of Nuclear Medicine. It is essential that only Isotopes we are authorised to possess are acquired, and that the total quantity on site at any one time does not exceed the maximum authorised amount. Exemption levels and exemption orders exist for some isotopes, however, these are not always applicable where the Trust holds a specific licence, and must not be assumed to apply. Where an authorisation does not exist for a specific isotope, a variation will have to be applied for from the Environment Agency before any radioactive material is acquired. A variation will take several weeks to obtain, and will incur a charge to the Trust. Where any radioactive material is to be acquired, the means of its subsequent disposal must be in place before acquisition. Authorisation is given for us to dispose of agreed maximum quantities of specific radioactive wastes in various forms (solid, liquid or gas) via approved routes, to specified destinations. Intended changes must be notified to the Environment Agency well in advance and any variations may take several weeks and will incur a charge on the Trust. From AOR2010: A Laser Protection Adviser (LPA) must be consulted by divisions before any laser therapy equipment is acquired or used. Risk Assessments must be carried out by divisions before installation and use of any laser therapy equipment in conjunction with the LPA. A generic risk assessment may be used to cover several pieces of similar equipment, used in a similar way, but there needs to be some acknowledgement in the records that such a risk assessment is still applicable, e.g. where loan equipment is in use. Radiation Protection Policy - 11 -

Adequate Training Divisions must ensure that operators of therapy laser equipment must have had adequate basic training in the use of lasers and specific applications training on the equipment used. Other persons who may be present must have sufficient training in the hazards involved and how to protect themselves. For Ultra-violet Light Sources: Consultation A suitable radiation protection adviser must be consulted by divisions to ensure that any health and safety requirements are adequately addressed. Risk Assessments must be carried out by the division before installation and use of any ultraviolet therapy equipment. Divisions must ensure that operators of therapy UV equipment have had adequate basic training in the use of UV and specific applications training on the equipment used. Other persons who may be present must have sufficient training in the hazards involved and how to protect themselves. Maintenance: Persons maintaining equipment must be aware of the hazard from UV light sources. It is essential that persons replacing any UV light sources such as fluorescent tubes are aware of the different types of UV light and that any replacement light sources are of the correct spectral and power output for the specific application. 6. Monitoring Compliance and Effectiveness Monitoring Requirement : The Radiation Protection Committee meets on a regular basis and receives reports from departmental managers, radiation protection advisers and radiation protection supervisors. Requests for reports will ask for specific information to provide assurances of compliance and for any areas where action is required. Where it is suspected that a person undergoing medical exposure or treatment has been exposed to a dose of ionising radiation much greater than intended, an investigation will be mounted by the Division or Divisions concerned. The investigation will need to determine whether the incident results from failure of the equipment or any other cause. It will also need to determine whether the incident requires statutory notification to the relevant competent authority according to guidance pertaining at the time of the incident. Where the incident results from a failure of equipment notification would be to the Health and Safety Executive, for other causes, notification would be to the IR(ME)R inspectorate at the Care Quality Commission. Radiation Protection Policy - 12 -

Monitoring Method: Reports will give an assessment of the level of compliance with regulations and highlight any areas of non-compliance or other issues that need to be brought to the attention of the Trust Board. The Trust board can then take such measures as it sees fit to rectify any deficiencies in compliance that cannot be dealt with within the committee and line management structure. Report Prepared by: Radiation Protection Officer Monitoring Report presented to: Radiation Protection Committee and Patient Safety Group Frequency of Report Bi -annual Radiation Protection Policy - 13 -

7. References 1. The Ionising Radiations Regulations 1999, HSE L121 2. The Ionising Radiation (Medical Exposure) Regulations 2000 (Amended 2006/11), Statutory instrument: Health and Safety 2000 No. 1059. 1 3. Medical and Dental Guidance Notes: A good practice guide on all aspects of ionising radiation protection in the clinical environment. IPEM 2002. ISBN 1-903613-09-4 4. Environmental Permitting Regulations 2010 (Amended 2012). 5. Artificial Optical Radiations at Work Regulations 2010 6. Guidance on the safe use of lasers, intense light source systems and LEDs in medical, surgical, dental and aesthetic practices (DB2008 (03), MHRA2008) Where it is suspected that a person undergoing medical exposure or treatment has been exposed to a dose of ionising radiation much greater than intended, an investigation will be mounted by the Division or Divisions concerned. The investigation will need to determine whether the incident results from failure of the equipment or any other cause. It will also need to determine whether the incident requires statutory notification to the relevant competent authority according to guidance pertaining at the time of the incident. Where the incident results from a failure of equipment notification would be to the Health and Safety Executive, for other causes, notification would be to the IR(ME)R inspectorate at the Care Quality Commission. Radiation Protection Policy - 14 -

Equality Impact Risk Assessment (EIRA) Cover Sheet Name of policy/process/service/function: Trust Policy for Radiation Protection Appendix 1 Policy /process/ service/function reference no: Person responsible for document: Simon Evans Division and Dept section: Imaging and Diagnostics Process being assessed is a: Guideline Written Policy Function or Strategy Service or Practice Informal policy Informal procedure Other (please state) New Existing Revised Lead person responsible for conducting the EIRA: Simon Evans Partners / Stakeholders (Internal and External) involved in the assessment: HSE, Trade Unions, Risk Committee, H&S Committee, Radiation Protection Committee To be completed on completion of the assessment if no relevance to inequality found Date screening completed: 17.02.2009 Date for screening review: To be completed if relevance found and full assessment undertaken Date screening completed Date full assessment completed Date for review Radiation Protection Policy - 15 -

Stage 1 Screening the process Q1. What is the aim and what are the key objectives of the Document? To ensure all radiation doses to all persons are kept as low as is reasonably practicable. Ensure annual dose to all persons does not exceed 300µSv per year from any single source, so far as is reasonably practicable. Q2. What outcomes or benefits is the document attempting to achieve, why and for whom? (e.g. What do you want to be providing, how well, changes, improvements; what benefits will there be?) Patient and Staff safety. Q3. What other key process/organisational documents does this link with? (Consider documents that will affect access to your Process and outcomes. Consider a joint EIRA if there are interlinking issues) Trust Policy for Compliance with Ionising radiation (Medical Exposure) Regulations 2000. Q4. Do you believe the document being assessed is relevant to the public sector equality duty in: Please tick all that apply: Eliminating Discrimination Promoting Equal Opportunities Promoting good relations between different groups identified in Q5 If you ticked any of the above the process will require a full assessment What do you/we already know? Q5. Is there any EVIDENCE or CONCERN from staff, users or communities that any of the following groups have been or could in any way be differentially impacted by the aims, Radiation Protection Policy - 16 -

objectives or implementation of the process? Is that differential impact positive or negative? N.B. A broad interpretation should be taken of the work evidence. It should include anecdotal evidence and evidence derived from qualitative or quantitative analysis where available). Group Yes No Positive Negative Age Gender (Male, Female and Transsexual)? Learning Difficulties / Disability or Cognitive Impairment? Mental Health Need? Sensory Impairment? Physical Disability? Race or Ethnicity? (Including cultural beliefs and norms) Religious, Spiritual belief Sexual Orientation? Homeless? Others Please state Please give details of the evidence you have: Q6. If you do not have any evidence for Q5 can you show that you have enough evidence to either demonstrate that the process will/ has not differentially impacted the groups or that the process is not applicable to differential impact assessment for these groups. Yes No If you answered No the process is likely to require a full assessment (please go to Q7) Radiation Protection Policy - 17 -

If you have tick Yes please detail what evidence you have: Next Steps: Q7. Does this document need to go onto full assessment? To decide whether your document needs a full assessment consider does your evidence indicate possible negative impact, how clear is the evidence you already have, are you confident in your evidence of no negative impact? Yes If you have ticked yes please go to Q9 No If you have ticked no please go to Q8 Q8. Briefly state your reasons for this Process not going onto a full assessment. Legislative Requirements Please now complete the screening review on the cover sheet Q9. If full Risk Assessment required use the EIRA prioritisation guide on page 19 please indicate if you feel the Process has a possible: High Risk of Impact Medium Risk of Impact Low Risk of Impact Please state the date you are going to begin the full assessment: Please now file a copy of your screening and send a copy to the Chair of the Equality and Human Rights Steering Group Please also connect your results / findings with whatever procedures or process for policy development that are relevant to your work or Division) Radiation Protection Policy - 18 -

Level of Impact Criteria Characteristics Actions HIGH The function is relevant to all parts of the duty There is substantial evidence of groups being adversely affected Potential for significant negative outcomes on different groups Potential for significant concern about how different groups are treated Frontline services with high scope for, or evidence of, unequal access or outcomes Strategic planning functions with direct impact on how services that have an equality dimension are organised Typically ACCESS to service /proposal by either Employees or Service Users may be raised at this level Proposal needs to be reviewed and amended as soon as possible and within 1 year There is substantial public concern MEDIUM The function is relevant to most parts of the duty There is some evidence of groups being adversely affected There is some public concern LOW All other functions (even ones with very little relevance). Potential for different groups to be inappropriately treated differently Potential for concern about how different groups are treated or that services are delivered differently Little or no potential for unequal access or impacts between different groups Frontline services with less scope for, or evidence of, unequal access or outcomes Strategic functions that could influence how different groups are treated Typically EPERIENCE of service / proposal by either Employees or Service Users may be raised at this level Back office support functions Direct service delivery where scope for different access or outcomes is limited Proposal needs to be reviewed and amended within 2 years Proposal needs to be reviewed and amended within 3 years Radiation Protection Policy - 19 -