Radiation Safety Initial Training Module 3 Policies and Procedures

In This Module Radiation Safety Initial Training Module 3 Policies and Procedures In order to work with or around radioisotopes at UAB, you should have a clear understanding of the policies and procedures. This module covers: Understanding the responsibilities of those working with or around radioactive materials; Obtaining, maintaining, and keeping a Radioactive Materials License; Using radioactive materials with animals; and Securing the lab. The Three Groups You Should Know There are three basic groups involved when talking about a Radioactive Materials 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 Laboratory Staff Must be listed as authorized users on the license, Must comply with all license conditions, and Are responsible for all safe and secure laboratory practices. The Licensee: Applies for, obtains, and maintains the license, and Complies with all license conditions. The Alternate (if named): If an Alternate is named, then his or her name appears on the license. And he or she has the same responsibilities as the Licensee. 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. Radiation Safety Module 3 Policies and Procedures Page 1 of 10 Last Updated: October 8, 2010

Obtaining and Maintaining a Radioactive Materials License The key to keeping a Radioactive Materials License is to maintain and adhere to the conditions stated on the license. The Licensee 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. Responsibilities of the Licensee and Alternate The Licensee 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. If an Alternate has been named and is listed on the license, then he or she has the same responsibilities as the Licensee. The Licensee and the Alternate must comply with the UAB Radiation Safety Procedures Manual, applicable regulations, and license conditions. 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 2) if 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. This is usually done on a quarterly basis. The Licensee and the Alternate must secure all radioactive materials from unauthorized access and seizure. The Licensee and the Alternate must carry out all of these responsibilities and more. But remembering every one of these on a day-to-day basis might be a problem. There is a PDF file of the Responsibilities of Licensees and Alternates on the home page of this course in the Resources section and on the OH&S web site for your convenience. Radiation Safety Module 3 Policies and Procedures Page 2 of 10 Last Updated: October 8, 2010

Onsite Presence of the Licensee/Alternate Required 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 Leave for the Primary Licensee 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. The primary Licensee must also 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 Employees or New to Working with Radioisotopes The Licensee is required to notify the OH&S Radiation Safety Program of new employees or those employees new to working with radioisotopes. 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. Baseline Bioassays Required! 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. Radiation Safety Module 3 Policies and Procedures Page 3 of 10 Last Updated: October 8, 2010

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. Regularly Scheduled Monitoring When Required 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. Radioiodinations Individuals performing Radioiodinations are also required to notify the OH&S Radiation Safety Program prior to performing each Radioiodination. Failure to do so is a VIOLATION of the regulations! If you need more information on this topic, please contact the OH&S Radiation Safety Program. Renovating 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 materials license, and include room diagrams of the new room or room changes if applicable. Decommissioning or Permanently Closing the 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. Radiation Safety Module 3 Policies and Procedures Page 4 of 10 Last Updated: October 8, 2010

According to new escalated enforcement actions, the Chairman of the Licensee s department will be held liable and responsible. This includes 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. Citations and Your Response We hope that you never receive a citation letter. However, should you receive one, you should respond as soon possible. Any UAB Radiation Materials Licensee and/or Alternate who does not respond to citation letters may have his or her license terminated. The manual covers the escalated enforcement actions. If you have questions, please call the OH&S Radiation Safety Program at (205) 934-2487. Responsibilities of the Laboratory Staff The laboratory staff usually carries on the day-to-day operations. Therefore, it is very important that you 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. Report all major spills to the OH&S Radiation Safety Program. Record and maintain all documentation. Pregnant? 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. Pregnant women who have declared their pregnancy MUST wear a Whole Body Radiation Dosimeter (WBRD) at the collar level. We strongly recommend that pregnant women who have declared their pregnancy wear a second Whole Body Radiation Dosimeter in the fetal area under a lead apron (if needed or required) when exposed to ionizing radiation. 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 or his designate. Radiation Safety Module 3 Policies and Procedures Page 5 of 10 Last Updated: October 8, 2010

The Personnel Monitoring Data Input Form The Personnel Monitoring Data Input form is online on the OH&S website in the Radiation Safety section. You MUST complete this form at the end of each day that you work with radioactive material. There are instructions on each screen to assist you. If you have questions about the form or how to use it, please contact the OH&S Radiation Safety Program. Radiation Monitoring Devices for Personnel Personnel issued radiation monitoring devices MUST be worn at all times while in areas where ionizing radiation is present. 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. No matter what type of device you wear, make sure that it remains in the lab when you leave. 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. Performing Surveys 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. These concepts will be demonstrated and practiced during the hands-on workshop. Documentation of Area Surveys Area surveys must be documented no more than seven (7) days after each date of radioisotope use and when significant contamination or radiation levels are found. Radiation Safety Module 3 Policies and Procedures Page 6 of 10 Last Updated: October 8, 2010

Daily and Weekly Surveys 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 counts per minute or 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. All weekly surveys must be documented. When Readings are 1,000 CPM Above Background! 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. Investigate to determine significant causes and prevent future events. Refer to the Procedures Manual for more information. Contamination Citations If an auditor finds an area that is contaminated, you will receive a citation letter. Make sure that all areas are free from contamination after working with radioactive materials. When auditors from the OH&S Radiation Safety Program visit for inspection (scheduled and unscheduled), they will perform their own surveys. As Low As Reasonably Achievable (ALARA) 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 exposures As Low As Reasonably Achievable. The acronym is ALARA. Radiation Safety Module 3 Policies and Procedures Page 7 of 10 Last Updated: October 8, 2010

The big three exposure reducing tools are time, distance, and shielding. To reduce your amount of exposure Spend less time near the radiation source. Move farther away from the radiation source 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, Shield first for beta radiation with Plexiglas or other appropriate material, and then 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. NEVER take shortcuts when working with radioisotopes! It only takes a second for an accident to happen and change a life forever. Everyone is responsible when it comes to ensuring the health and safety of those in the lab. Follow the ALARA principles stated here to stay safe when working with radioisotopes. Inventory Submission, Dates, Grace Periods, and Citations 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. An annual calendar with these dates marked is available on the home page of this course and on the website, but mark your own calendars as well. 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. 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 for a late submission. Radiation Safety Module 3 Policies and Procedures Page 8 of 10 Last Updated: October 8, 2010

Submitting a Quarterly Inventory Remember to submit the online inventory form each quarter even if you have no radioactive materials to report. If you have no radioactive materials to report and wish to keep the license active, there is a place on the form to indicate No radioactive materials. Failure to submit an online inventory form could result in the termination of the license. Animals and Radioisotopes 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: Contact OH&S Hazardous Materials Facility for disposal, or Decay the cages in the lab & then contact OH&S about disposal, or Follow other procedures as designated for your lab. With reusable cages: Clean them thoroughly & then monitor for CPM levels before returning to the Animal Resources Program (ARP). Remove all radiation markings and labels. 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. Dispose of the bedding, carcasses, contaminated cages, and other potentially contaminated materials in accordance with the Radioactive Materials license. Contact the OH&S Radiation Safety Program, the Hazardous Materials Facility, or the Animal Resources Program if you have any questions. Radiation Safety Module 3 Policies and Procedures Page 9 of 10 Last Updated: October 8, 2010

Securing Radioactive Materials and Regulations 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. Dramatization In the Resources section of this course, is a short movie. It is a theatrical production. It was created to show you what could happen in one of UAB s labs. This has NEVER happened on UAB s campus. When you follow security guidelines, it ensures that an incident of this nature will NOT happen at UAB. Remember, it is fictional a staged production. Please make sure that you watch the movie. There will be questions on it in the quiz. And in Closing Remember 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 and the Radioisotope & Radiation Safety Committee wants you to know that your knowledge and compliance of the policies and procedures works to keep us all safe. This concludes Module 3 Radiation Policies and Procedures. Return to the home page of this course and take the quiz. You must score 80% or higher to pass. When you pass, Module 4 Ordering, Receiving, Transferring, and Disposal of Radioactive Materials at UAB will open. Radiation Safety Module 3 Policies and Procedures Page 10 of 10 Last Updated: October 8, 2010