OH&S Radiation Safety Refresher Course Materials Note: This information is almost the same as the Flash file in the course. Some of it has been modified for reading purposes. Other information was not included; for example, the security video. Refresher Training Requirements The OH&S Radiation Safety Program, which is licensed by the State of Alabama, requires that UAB employees who work with radioisotopes complete a radiation refresher course every five years. Most of us concentrate on our day-to-day activities and begin to take short cuts. This information serves as a reminder of the way things are supposed to be done as well as covering new policy and procedure changes. Special Notes: The glossary for the Radiation Safety courses is located in this course and OH&S website. If you have questions about any of the terms, please call the OH&S Radiation Safety Program. The RRSC, Licensee/Alternate, and the Lab Staff There are three basic groups involved when talking about a Radioactive Material License - The Radioisotope & Radiation Safety Committee (the RRSC), the Licensee and the Alternate, and the Laboratory Staff. Communication between the UAB Radioisotope & Radiation Safety Committee (the RRSC) and the Licensee and between the Licensee and the laboratory staff is necessary to ensure that all the policies and procedures are followed to maintain safety and security. The UAB Radioisotope and Radiation Safety Committee (the RRSC) Approves licensure, Enforces the conditions of the license, Suspends the work in a laboratory due to violations and Can terminate the license. The Licensee: Applies for, obtains, and maintains the license, and Complies with all license conditions. If an Alternate is named, then his or her name appears on the license. The Alternate will have the same responsibilities as the Licensee. The Laboratory Staff Are listed as authorized users on the license, Must comply with all license conditions, and Are responsible for all safe and secure laboratory practices. The OH&S Radiation Safety Refresher Course Page 1 Last Updated: 05/14/2012
The Licensee and Alternate Responsibilities The key to keeping a Radioactive Material License is to maintain and adhere to the conditions stated on the license. The Licensee, and Alternate if named, should be very familiar with what is stated in the license. This is the person who is ultimately responsible for the people, the radioactive materials, and the lab. The Licensee, and Alternate if named, has many responsibilities since he or she must adhere to the conditions of the license as well as other rules and regulations. The major points have been covered here. The Licensee and the Alternate must provide and enforce the written laboratory safety procedures and the instruction of the supervised personnel. The Licensee and the Alternate must require personnel to wear clean, buttoned laboratory coats and protective gloves while handling radioisotopes. The Licensee and the Alternate must make available properly operating radiation detection instruments, both bench and portable types, appropriate to detect the type of radiation being measured. The Licensee and the Alternate must procure all material, equipment, and posting needed in all facets of the radiation safety program. The Licensee and the Alternate must authorize/approve purchase requisitions for radioisotopes only if: 1) they are of the type and chemical form authorized by the license, and if 2) the receipt of the order does not cause possession limits to be exceeded. The Licensee and the Alternate must maintain up-to-date records showing the receipt, use, disposal, and transfer of all radioactive material. The Radioactive Material Transfer forms and the Radioactive Material Record forms can be obtained from the OH&S Radiation Safety Program. The Licensee and the Alternate must conduct inventories of nonexempt radioisotopes at times specified by the Radiation Safety Officer (RSO). This is usually done on a quarterly basis. The Licensee and the Alternate must secure all radioactive materials from unauthorized access and seizure. Note: A PDF file of the Responsibilities of Licensees and Alternates can be found on the OH&S web site for your convenience. The OH&S Radiation Safety Refresher Course Page 2 Last Updated: 05/14/2012
Physical Presence in the Lab Licensees and/or Alternate Licensees are not required to be physically present in the area during radioactive materials use IF the following conditions are met. 1. The Licensee/Alternate has determined that the workers are competent to safely use the materials by themselves. 2. The Licensee/Alternate is available to respond and assist them in case of an emergency. This requires the Licensee/Alternate to be less than a one (1) hour drive away from the facility. Extended Absences There may be times when the primary Licensee may be absent for an extended length of time. Should this happen, then the primary Licensee MUST Obtain the written consent from the Alternate Licensee to supervise the primary s radioisotope program during his/her absence. If this is NOT done, these activities must cease during such absence. An e-mail conversation is considered written consent. Notify the OH&S Radiation Safety Program prior to an extended absence from the University if radioisotope activities will continue to be conducted under the license. New Personnel The Licensee is required to notify the OH&S Radiation Safety Program of new employees or those employees new to working with radioisotopes as soon as possible. Once the OH&S Radiation Safety Program has been informed of the new employee, they will: perform a Baseline Bioassay, evaluate and complete training if necessary, and add the person to the license. A new person, whether new to UAB or working with unsealed radioisotopes, can be added to the license as a closely supervised authorized user. However, all training must be completed within six months. This means that this person MUST NOT be left alone while working with unsealed radioisotopes until all training has been completed. The person supervising MUST be an authorized user on the license who has completed all required radiation safety training. The OH&S Radiation Safety Refresher Course Page 3 Last Updated: 05/14/2012
The Baseline Bioassay Since natural radiation exists in everyday life, new employees or those new to working with or around radioactive materials are required to have a baseline, or pre-operational, bioassay performed. This allows the OH&S Radiation Safety Program to know exactly how much radiation is already a part of the person s body so that if he or she should be internally contaminated, OH&S would be able to determine the difference in those two amounts. No one should be working with unsealed radioisotopes without having a baseline bioassay on file! To do so is a violation of the regulations. To schedule bioassays, contact the OH&S Radiation Safety Program. Personnel Monitoring The OH&S Radiation Safety Program (RSP) and all UAB Licensees and their Alternates are responsible for ensuring that all personnel working with radioisotopes participate in an ongoing, regularly scheduled monitoring program, when required. Only the OH&S Radiation Safety Officer (RSO) shall determine whether such monitoring is no longer necessary. The online version of the Personnel Monitoring Data Input Form now replaces the paper copy. It is located on the OH&S website in the Radiation Safety section. There are instructions on each screen to assist you. There are only four fields for your data the date, the BlazerID, the Material, and the Amount. Enter each radioactive material that you used for that day as well as the amount. Use the Submit button and the Complete button to enter your items. Do NOT use the Enter button. You MUST complete this form at the end of each day that you work with radioactive material. If you have questions about the form or how to use it, please contact the OH&S Radiation Safety Program. For more information, review the form on the OH&S website. The OH&S Radiation Safety Refresher Course Page 4 Last Updated: 05/14/2012
Radioiodinations Ordering Individuals performing radioiodinations are required to notify the OH&S Radiation Safety Program for approval prior to performing each radioiodination. Failure to do so is a VIOLATION of the regulations! When ordering radioactive materials remember - All orders for radioactive materials MUST be processed through Oracle and the OH&S Radiation Safety Program (RSP). Laboratories are NOT allowed to phone in orders to vendors unless the Licensee has special approval to do so. To order: 1. Submit a purchase order request in Oracle. 2. When the request is approved and a PO number is received, the OH&S Radiation Safety Program will phone in the order. Warning! Only those persons licensed by the RRSC may receive radioactive material. Licensees may not receive radioactive materials directly from a vendor unless given special approval by the Radiation Safety Officer (RSO) or his designate or is so approved by a condition on the UAB Radioactive Material License issued to them. Pages 43 and 44 in the manual and the OH&S website have more information on how to complete the purchase order requisition. Complete the purchase order request as stated in the manual to expedite your order. Contact the OH&S Radiation Safety Program if you have any questions. Decommissioning a Lab Decommissioning, or permanently closing the lab, is a responsibility of the Licensee and/or the Alternate. There are serious repercussions if a lab is abandoned at UAB. If you are the primary Licensee and plan on leaving UAB permanently, you MUST notify the OH&S Radiation Safety Program at least one month prior to terminating employment at UAB. This is to ensure that adequate arrangements are made for the transfer and/or disposal of all radioisotopes in the licensee's possession. Perform a wipe test after transferring or removing everything radioactive from the laboratory. This must be done to verify that nothing in the room is radioactive. The OH&S Radiation Safety Refresher Course Page 5 Last Updated: 05/14/2012
Amending a License For New Radioisotopes Not on the License Before you can order materials that are not listed on your license, you must request in writing any change you wish reflected on your Radioactive Material License. Changes made to a license are called amendments. Also, an e-mail is considered a request in writing. When amending your license, request families of organic compounds instead of specific organic compounds when possible. For example A Licensee wants to add 3 H to his/her license, but the 3 H has five different chemical forms. All five are included in the family of amino acids. The amendment would request 3 H with amino acids instead of five separate chemical forms. If you need help with amending your license for new materials, please refer to the manual or contact the OH&S Radiation Safety Program for more information. For Renovations or Moving When renovating or moving, the Licensee must submit the changes to the OH&S Radiation Safety Program and wait for approval! Request an amendment in writing which includes any change you wish reflected on your Radioactive material license, and include room diagrams of the new room or room changes if applicable. Again, an e-mail is considered in writing. Citation Letters Any UAB Radiation Material Licensee and/or Alternate who does not respond to citation letters and/or receives repeat citation letters may have his or her license terminated. The manual covers the escalated enforcement actions now in effect. If you have questions, please call the OH&S Radiation Safety Program at (205) 934-2487. The Responsibilities of the Lab Staff The laboratory staff usually carries on the day-to-day operations. The lab staff should: Meet the training requirements. This means initial training followed by a refresher course every five years. Abide by established safety and security procedures. This means those listed on the license and in the procedures manual. The OH&S Radiation Safety Refresher Course Page 6 Last Updated: 05/14/2012
Report all major spills to the OH&S Radiation Safety Program. Record and maintain all documentation. ALARA Dosimetry The occupational doses received by laboratory radiation workers are usually far below the doses which would induce any acute effects from the radiation. However, because of the uncertainties that exist with any individual radiation dose, occupationallyexposed individuals should always strive to keep their occupational exposures As Low As Reasonably Achievable (ALARA). The big three exposure reducing tools are time, distance, and shielding. To reduce your amount of exposure Time - Spend less time near the radiation source. Distance - Move farther away from the radiation source Shielding - Use the appropriate shielding for the radiation source Use the proper shielding - whether it's Plexiglas, lead bricks or pigs, a lead apron, or a combination. Just remember, when shielding radioactive materials, 1. Shield first for beta radiation with Plexiglas or other appropriate material, and then 2. Shield second for gamma radiation with lead of appropriate thickness. Perform a mandatory documented Area Survey (a wipe test) within seven days after using radioactive materials. Note: A wipe test must be performed if you are using 3H and 14C. A Geiger counter cannot detect 3H and is unreliable when trying to detect 14C. Therefore, a wipe test must be performed for both. Abide by established safety and security procedures, as listed on the license and in the procedures manual. And last, but not least... NEVER take shortcuts when working with radioisotopes! It only takes a second for an accident to happen and change a life forever. If you are the Licensee/Alternate, you are responsible for those working in your area. All of the above could all have potentially dangerous effects not only on the employees, but could jeopardize your license. Employees who are issued radiation monitoring devices MUST wear them at all times while in areas where ionizing radiation is present. The OH&S Radiation Safety Refresher Course Page 7 Last Updated: 05/14/2012
The Licensees, Alternates, and Supervisors are responsible for ensuring that all personnel wear their radiation monitoring devices while working with certain types and amounts of radioisotopes. The devices should stay in your lab and not go with you out to another lab, another building, or home. If you are leaving, take it off. Remember to put it back on before working with ionizing radiation again. Declaring a Pregnancy Women who are pregnant, should tell, or declare, their pregnancy to the supervisor and the OH&S Radiation Safety Program so that all precautions may be taken to protect the mother and the fetus. It is not the responsibility of the Supervisor, Manager, Licensee or Alternate, or OH&S to report a worker s pregnancy. Women who have declared their pregnancy MUST wear a Whole Body Radiation Dosimeter (WBRD) at the collar level. Pregnant women who have declared their pregnancy must wear a second WBRD in the fetal area. If a lead apron is required while working with radioisotopes, the second WBRD should be worn under the lead apron in the fetal area. More dosimetry may be used by a declared pregnant radiation worker upon request or in special circumstances with the approval of the Radiation Safety Officer (RSO) or his designate. Area Surveys, Wipe Tests, and Contamination Amounts We expect some contamination to be in areas where work with radioisotopes occurs. There are two ways to test for contamination an area survey or a wipe test. An Area Survey for radiation is an evaluation of the hazard related to the possession, production, use, transfer, and release of radiation. A Wipe Test is a method commonly used to detect and measure the presence of removable radioactive contamination. When performing surveys, don t forget that other areas could have been possibly contaminated for example: floor areas, door knobs or handles, refrigerator handles and doors, swipe cards, as well as other items. Check these areas periodically. Area surveys must now be documented no more than seven (7) days after each date of radioisotope use and when significant contamination or radiation levels are found. The laboratory area must be surveyed when work is finished or when leaving for the day after working with radioisotopes. If no radioactive contamination is found (less than 100 CPM above background), no documentation is necessary. However, if greater than 100 CPM above background is found, then a wipe test must be performed. After the first wipe test is performed, clean the area and then perform another wipe test. Both tests must be documented and kept in your files. The OH&S Radiation Safety Refresher Course Page 8 Last Updated: 05/14/2012
All weekly surveys must be documented. When a wipe test shows readings of 1,000 CPM above background, declare the laboratory area contaminated; clean the area; perform another wipe test. Keep the results of this test in your files; notify the OH&S Radiation Safety Program immediately; require bioassays for all who were working at or near the area; and investigate to determine significant causes and prevent future events. Refer to the procedures manual for more information. If an auditor finds an area that is contaminated, you will receive a citation letter. Make sure that all areas are free from contamination. When auditors from the OH&S Radiation Safety Program visit for inspection, they will perform their own wipe tests. Quarterly Inventory Reports Your inventory must be submitted online each quarter. Inventory due dates are March 27 th, June 27 th, September 27 th, and December 27 th each year. You have a grace period of 14 days. The count starts the day after the 27 th of the month. Weekends and holidays are included in the 14 day count! If your online inventory form is NOT submitted by the end of the day when the grace period ends, it is considered LATE and a citation will be issued. An annual calendar with these dates marked is available on the OH&S website, but mark your own calendars as well. If you are out of the office when the grace period ends and you have not submitted your quarterly inventory, you will still receive a citation letter for a late submission. Failure to submit the online inventory form each quarter could result in the termination of the license. Paper copies will not be accepted. See the policy for more information. If you have no radioactive materials to report, you still have to submit an online form each quarter as long as the license is active. There is a place on the online form to indicate No radioactive materials. The OH&S Radiation Safety Refresher Course Page 9 Last Updated: 05/14/2012
Handling Radioactive Waste There are strict procedures for the disposal of radioactive waste material. Different forms of radioactive wastes must be collected and packaged according to the procedures described for each form. According to new escalated enforcement actions, the Chairman of the Licensee s department will be held liable and responsible including any costs for the transfer and/or disposal of all radioisotopes if the Licensee terminates employment at UAB without notifying the OH&S Radiation Safety Program. The different physical forms specified are solid wastes, liquid wastes, Liquid Scintillation Counter Vials (LSC or LSV), and animal tissue wastes. Separation of Waste Radioisotopes must be collected in separate containers to minimize the accumulation of waste. Please see the manual for more information. Mixed Waste Special approval through licensure must first be obtained if the experimental protocol or laboratory test requires a dual or multiple labeling procedures that makes separation impossible. Waste Accumulations The volume of radioactive waste packages allowed to accumulate within UAB laboratories should be kept to reasonable amounts. The accumulation shown in this picture is NOT a reasonable amount! This is a danger to both you and those in the area. If the radioactive waste is contaminated with infectious materials, kill all the biological hazards or inactivate them as described in the UAB Biosafety Manual. Identify compounds that are present at levels greater than 0.5 percent by weight on the manifest and adjust solutions for a ph in the range 5 to 9 before pickup. Radioactive contaminated solid waste must be collected in fiberboard boxes lined with a plastic liner of at least two mil thickness. Examples of solid waste materials are paper, plastic, glassware, gloves, bench paper, and animal bedding. When boxing radioactive waste, use fiberboard material. The box should be no larger than 24 inches on a side. Filled weigh should be no more than 50 pounds. The OH&S Radiation Safety Refresher Course Page 10 Last Updated: 05/14/2012
An inner plastic liner should be placed within each package. It must be sealed to contain any leakage during handling. Sharps should be placed in approved, rigid, puncture-resistant collection containers (Sharps containers). Examples are thin Pasteur pipettes, needles, and razors. All packages MUST contain the following on the outside of the package - Name of Licensee or Alternate, Isotope, Activity, Building, and the Room Number. Remember, all hazardous waste MUST be identified regardless of the concentration! Before packaging liquids remember that: The containers for liquids must be completely devoid of any solid radioactive waste; Liquids MUST be separated from solid wastes so that there is no more than 0.5% (by weight) of free standing liquids. Boxes SHOULD NOT LEAK especially those containing hazardous waste. Always pack the waste materials correctly. If you have questions, call OH&S at (205) 934-2487. Liquid containers must be made of a durable material of substantial thickness to prevent breakage or cracking and subsequent leakage. Liquid radioactive wastes that are aqueous and contain 2.5% or less chemicals may be collected in regular polyethylene and polypropylene containers. Other radioactive liquid wastes, especially those containing organic solvents, should be collected in the following types of containers: durable glass, acetal plastic, or high-density polyethylene fluorocarbon treated plastic, which is similar to nalgene. If glass jugs are used as collection containers, then there must be a shock absorbing partition (i.e. fiberboard) between collection containers within the package to prevent breakage. The best method of collection is in the trays in which some of the vials are packed, usually 100 vials per tray, when purchased. If they are not collected in trays, then they must be placed within a plastic liner of at least four mil thickness. Two plastic liners of two mil minimum thickness are required. The trays or bags of vials must be placed in fiberboard boxes for disposal and subsequent transport to the Hazardous Materials Facility. There could be a $50.00 disposal charge when the UAB Support Facility (formerly known as the Hazardous Waste Facility) is asked to pick up certain types of Liquid Scintillation Vials. This charge applies to containers holding unknown materials as well. The OH&S Radiation Safety Refresher Course Page 11 Last Updated: 05/14/2012
In order to avoid this charge, aspirate (remove the liquid) into an acceptable container. See the manual for a list of appropriate containers. The Radioactive Waste Manifest When the waste has been properly packaged, complete the Radioactive Waste Manifest online. Paper manifests are no longer accepted. The Licensee, the Alternate Licensee, or an Authorized Worker may now electronically sign the online manifest. Make sure that you include the license number and BlazerID. Instructions can be found on the second page of the manifest. E-mail the manifest to radwastemanifest@uab.edu. Incorrectly completed and paper manifests will be returned for correction. Use the waste packing checklist on the website to ensure that your manifest and boxes are correct. Radioisotopes and Animals When radioisotopes are used with animals, other policies and procedures are added - signs, markings, cleaning, and waste disposal. If you work with radioisotopes and animals, make sure you follow these procedures. In order to work with animals and radioactive materials, you must complete and submit an Animal Use Safety Information form also known as the AUSI. This form must be approved before work can begin. The AUSI is available at http://main.uab.edu/internal/show.asp?durki=35931. The approved AUSI and a Radioactive Materials sign must appear on the door to the animal area. All areas, doors and cages, must be clearly marked to indicate radioactive materials are present. The name(s) of the isotope(s) must also be listed. Disposable or reusable animal cages are handled differently. With disposable cages: 1. Contact UAB Support Facility for disposal, or 2. Decay the cages in the lab & then contact OH&S about disposal, or 3. Follow other procedures as designated for your lab. With reusable cages: 1. Clean them thoroughly & then monitor for CPM levels before returning to the Animal Resources Program (ARP). 2. Remove all radioactivity markings and labels. 3. Perform a wipe test and record the results to give to the ARP. Warning! Do NOT allow reusable cages to decay-in-place! If you do, it may result in ARP charges. Follow all other radioisotope procedures (wipe test, survey, etc) for both disposable and reusable cages. Contact OH&S or the ARP if you have questions about proper handling. The OH&S Radiation Safety Refresher Course Page 12 Last Updated: 05/14/2012
Dispose of the bedding, carcasses, contaminated cages, and other potential contaminated materials in accordance with the PIs Radioactive Materials license. If you have questions, please call the OH&S Radiation Safety Program. Security Issues and Radioisotopes Since 2001, increased emphasis is placed on the security of radioactive materials by regulatory agencies, such as the Nuclear Regulatory Commission (NRC). The Alabama rules for Radiation Control require that: sources of radiation stored in unrestricted areas be secured to prevent unauthorized removal; and sources of radiation in any unrestricted area shall be tended under the constant surveillance and immediate control of the Licensee. UAB, in accordance with these rules and regulations, requires that radiation storage facilities located in a hall or in any area open to the public must be kept locked and labeled at all times. Also, ALL radioactive materials must be safely secured in the lab when no one is present. Just a Reminder As we go about our daily activities, sometimes we get careless and don t pay close attention to what s going on around us. We acknowledge people coming in and out without badges assuming they are students or UAB employees. We take food and drink into the lab or store it in refrigerators with chemicals and radioactive materials. We forget to button our lab coats and to remove our gloves when leaving the lab. All of these are serious safety and security issues at UAB. The OH&S Radiation Safety Program in conjunction with the Radioisotope & Radiation Safety Committee wants you to know that your knowledge of these issues along with your compliance of the policies and procedures works to keep us all safe. Recertification and the Quiz You should now take the quiz. 80% or higher is required to pass. Recertification is required every five years. You may check your training by going to My Transcript, clicking on Date Range Complete History, and looking for your training there. This is also where you may obtain your certificates of completion. If you still don t see your Radiation Safety training listed and KNOW that you ve completed it, please e-mail Robert Heath at rheath@uab.edu for verification. The OH&S Radiation Safety Refresher Course Page 13 Last Updated: 05/14/2012