Section 2: Radioactive Materials Use

Contents

2.1  General

Radioactive material use at Syracuse University is bound by the limits and requirements established in the University’s New York State Department of Health issued Broad Scope Radioactive Materials License. This License imposes limits on the quantities, types and forms of radioactive materials that can be possessed at the University and outlines specific requirements that must be encompassed in the University’s Radiation Protection Program. All aspects of the purchasing, use and disposal of radioactive materials at the University must comply with the terms of the University’s Radioactive Material License and New York State regulations.

This Section of the Radiation Protection Program Handbook outlines the requirements and procedures for purchasing and using radioactive materials at Syracuse University. It also provides detailed information on the requirements for becoming an approved Radioactive Material Supervisor and a Radioactive Material Worker.

2.2 Radioactive Material Supervisor – Application for Use of Radioactive Material

Radioactive Material Supervisors (RMSs) are members of the University faculty or staff who are authorization to perform specific procedures involving radioactive materials from the University’s Radiation Safety Committee (RSC). Prior to commencing work with radioisotopes, these individuals must complete and submit an “Application for Use of Radioactive Material”  (Application) to the RSC for review and approval. The RSC will grant approval, conditional approval, or disapprove of the Application based on the information provided, the applicant’s experience with radioisotopes, and the effect the proposed use will have on University property and the safety and health of the University community. This Handbook Section describes the application process used at Syracuse University to evaluate prospective RMSs and proposed uses of radioactive materials.

(i) Completing and Submitting an Application

Prospective Radioactive Material Supervisors may obtain an Application from science department offices or from the Environmental Health and Safety Service Office. The Application must be completed in full and typed to ensure legibility. The following information must be provided in or as an attachment to the Application:

  • A list of all individuals who will be working with radioactive materials under the applicant’s supervision
  • A justification of the need to use radioactive materials
  • Procedures for proposed operations which involve the use of radioactive materials sufficiently detailed for evaluation of the associated hazards
  • A copy of the applicant’s current Curriculum Vitae
  • A description of applicant’s previous training and experience with radioactive materials including dates, locations, isotopes, processes, etc.
  • A floor plan of the radiation use areas, including major pieces of equipment to be used (i.e. refrigerators, freezers, fume hoods, centrifuges)
  • A description of the equipment that will be available to survey, control and/or minimize the radiation hazard
  • Estimates of types and quantities of radioactive waste that will be generated

Detailed instructions for completion of an Application are provided with the Application. Radiation Safety staff will provide further assistance and answer questions related to the Application upon request.

Once the Application is complete, the applicant must submit it along with any attachments to the Radiation Safety Committee (RSC) via the Radiation Safety Officer (RSO). The RSO will complete a radiological safety evaluation of the Application consisting of a review of the Application, an interview with the applicant, and a visit to the applicant’s laboratory (as necessary). Upon completion, the RSO will summarize the evaluation in writing.  This evaluation summary will consist of an item‑by‑item analysis of the Application and the RSO’s recommendation(s).

The Application, attachments, and RSO evaluation are then forwarded to each member of the Radiation Safety Committee for comment and action. Questions from members of the RSC will be addressed appropriately by either the RSO or the applicant.  Approval, disapproval or conditional approval will be by majority opinion of the technical members of the Radiation Safety Committee. Records of applications, evaluations and RSC actions will be kept for review by EHSS.

Following approval by the RSC, the RMS becomes responsible for all radiation related activities performed or required to be performed in accordance with the conditions of approval. Responsibilities include, but are not limited to, the purchase, use and storage or all radioactive sources; the handling and tracking of radioactive waste; the performance and documentation of required surveys; etc. The RMS is responsible for ensuring that individuals in their laboratory who work with ionizing radiation or who are exposed to ionizing radiation as a result of activities conducted under their supervision, are properly trained and aware of the related hazards. The RMS must also ensure that only approved radioactive material procedures are performed in the laboratory and that the RSO is notified of any changes in use areas, individuals or procedures. A summary of the responsibilities of a RMS are provided in Section 1.3 of this Handbook.

Any additions or modifications to approved procedures or radioactive material use in the laboratory that could potentially increase or modify the radiation hazard previously evaluated or introduce a new hazard, must be approved by the RSC prior to commencement. Amendment requests including a revised “Application for Use of Radioactive Material” should be submitted to the RSC via the RSO.

(ii) Evaluation of an Application

Applications for use of radioactive material are evaluated in terms of the qualifications of the applicant and the use(s) of radioactive material proposed. A Prospective Radioactive Material Supervisor is evaluated based on the isotopes and activities proposed for use and his/her past experience with radioactive materials in terms of time, toxicity, activity and type used. In general, a RMS must:

  • Be a permanent or contract member of the University faculty or staff.
  • Be the senior researcher of the project and directly responsible for radioactive material use in the laboratory.
  • Be the senior occupant of a facility(s) suitable for the proposed work or be authorized to use a suitable facility by the facility’s senior occupant and the RSO.
  • Be knowledgeable of the University’s Radiation Protection Program requirements and related regulations.

The following table is a guideline for evaluating a prospective user’s training and experience, however, this table is not the sole method used to judge an applicant’s authorization:

Authorization Guidelines Table
Authorized Radioactive Inventory (Requested) Individual’s Training & Experience (documentation required)
I. 0-10 control units* of any nuclide for which the University is licensed Successful completion of academic courses pertaining to or satisfactorily demonstrating competency and knowledge of the: 1) Principle and practices of radiation protection, 2) Radiation instrumentation and monitoring, 3)Radiation related biological affects, 4) Basic radiation calculations and physics, and 5) Sufficient radioisotope experience to assure safe handling and appropriate exposure control.
II. 10 – 500 control units* of any nuclide for which the University is licensed Same as I. above plus 1 year experience using radioisotopes of similar form, activity, toxicity, etc. as requested for authorized possession.
III. 10 – 500 control units* of any nuclide for which the University is licensed Same as I. above plus 3 years or more  experience using radioisotopes of similar form, activity, toxicity, etc. as requested for authorized possession.
*Control units any radioisotope correspond directly to the quantities listed in Section 10.4 of this Handbook.

Proposed uses of radioactive material and associated operations are generally evaluated based on the following items. However, other items or concerns specific to particular applications may also be taken into consideration in the evaluation.

  • The isotopes requested for use, their requested possession limits and their associated classification of toxicity
  • The applicant’s justification of the need to use radioactive materials
  • The potential for exposure to personnel, the methods that will be employed for personnel monitoring and the steps that will be taken to insure that the potential exposures are kept “as low as reasonably achievable” (ALARA)
  • The facility and equipment available to the applicant, including personnel protective equipment, shielding, survey instruments, fume hoods, etc.
  • The types and quantities of wastes expected to be generated
  • The types of containment that will be used with radioactive materials, including primary and secondary containment when working with liquids
  • The ability of the Applicant to complete and implement a decommissioning plan for all affected facilities and equipment.

2.3 Procedure to Become an Approved Radioactive Materials Worker

Syracuse University requires that anyone who wishes to work with radioactive materials has a thorough understanding of regulations and hazards associated with the use of ionizing radiation. This is accomplished through a two-stage radiation worker training program. Stage One of this program involves a series of videotapes, a class room lecture and an examination. Stage Two is completed in the laboratory under the direct supervision of an approved radioactive material worker. Individuals who do not have adequate, previous experience in using radioactive material must complete Stage One requirements prior to commencing work with radioactive materials. Adequately experienced individuals may complete Stage One and Stage Two requirements concurrently. The following lists the steps for completing both stages of the required radiation worker training program:

Stage One

 

  1. Notify the Radiation Safety Officer (RSO) of your intention to become a radioactive material worker by completing a “Radiation Worker Sign‑Up” form. This form may be obtained from the Environmental Health Office at 029 Lyman Hall, ext. 4132.
  1. If you have ever been monitored for radiation exposure or are currently being monitored for radiation exposure at another institution, complete a “Radiation Exposure History Request” form. This signed form will allow the University to request and receive your exposure history from the other institution.
  1. Sign out a copy of the University’s Radiation Protection Program Handbook and read it to familiarize yourself with the terms and concepts of radiation protection. Particular emphasis should be placed on understanding rules and regulations for using radioactive materials at Syracuse University.
  1. Schedule a time with the Radiation Safety staff, ext. 9130, to view videotapes on the safe use and handling of radioactive materials, radiation hazards and associated risks, and emergency procedures. These tapes may be viewed at EHSS during normal working hours.
  1. If you have previously used radioactive materials in applications similar to those anticipated to be used at Syracuse University:
    • Summarize your experience in writing and submit it to the RSO for review, including dates, locations, isotopes, activities, and an explanation of related experimentation.
    • Take a preliminary examination which will evaluate your knowledge with respect to radiation safety, associated hazards and the use of radioactive materials.
    • Upon satisfactory completion of the examination and authorization from the RSO, you will be granted a conditional approval to work with radioactive materials in the laboratory under direct supervision and may begin completing the Stage Two training requirements. Dosimetry will be issued to monitor your external radiation exposure (as applicable).
    • The retention of the conditional approval is contingent upon your attendance at the next radiation worker training class and the completion of the remaining Stage One requirements. If these requirements are not met with-in 3 months of obtaining conditional approval, your conditional approval will be revoked until the requirements are completed.
    • If you do not satisfactorily complete the examination or if the RSO determines that your previous experience is insufficient for your intended radioactive material use at Syracuse University, conditional approval will not be granted until completion of all Stage One training requirements.
  1. Attend the next Radioactive Material Worker Training Session (offered as needed, approximately 4 times a year). This session covers rules, regulations, and procedures as well as proper surveying methods and monitoring devices. This session generally lasts for three hours and is mandatory for every new open source, radioactive materials worker.
  1. Take an examination which evaluates your knowledge of the elements of the University’s Radiation Protection Program, general radioactive materials use, biological effects, associated hazards, related rules and regulations, and radiation terminology.
  1. Schedule a meeting with the RSO to review your test results and go over any questions you may have.
  1. Upon the successful completion of these requirements you will be conditionally approved as a radioactive material worker. Work with radioactive material may be performed only under direct supervision by an approved radiation worker. Dosimetry will be issued to monitor your external radiation exposure (as applicable).

 

Stage Two

 

  1. Prior to using any radioactive materials in the laboratory, complete a radioactive material laboratory orientation with your radioactive material supervisor or an approved radiation worker. Document this training on the “Laboratory Orientation” form and return the completed form to the RSO, 029 Lyman Hall.
  1. Complete 40 hours of supervised on‑the-job training as related to radioactive materials and/or processes and document this training on the “Supervised Training” form. This training should be completed within 4 months of obtaining conditional approval. If additional time is necessary, a written request must be submitted to the RSO.  Return the completed form to the RSO.If you have documented adequate, previous experience using radioactive materials in applications similar to those anticipated to be used at Syracuse University, some or all of the required 40 hours of supervised training may be waived at the discretion of the RSO.
  1. Once you have satisfactorily completed the above process, you will be granted approved radioactive material worker status. The status may be continued perpetually by completing the required annual refresher training.

2.4 Radioactive Material Inventory Control

Syracuse University’s Radioactive Material License requires that an active inventory of all of its non-exempt radioactive sources, including open sources, sealed sources and sources enclosed in equipment (i.e. gas chromatograph), be maintained.  To ensure compliance with this requirement, Radiation Safety staff must be notified prior to the purchase or receipt of any radioactive material.  All requests for purchase of radioactive materials must be reviewed by Radiation Safety staff to ensure that possession limits will not be exceeded. Radioactive material purchases will not be authorized if the additional activity will cause the RMS to exceed maximum possession limits.  All radioactive material deliveries must be received at the Radiation Safety Laboratory, room 034 Lyman Hall, so that the necessary inventory information can be recorded.

A database of active radioactive material sources possessed at the University is maintained by Radiation Safety staff to track the sources from purchase to disposal.  Each radioactive material source received is assigned an inventory number and recorded in the database. When Radiation Safety staff deliver the radioactive material source to the RMS, it is accompanied by an inventory sheet indicating the isotope and activity of the source and the assigned inventory number.  All use and disposal of the radioactive material must be entered onto this sheet, as indicated.   The sheet must be kept up to date and may be stored in Section 12 of this Handbook for easy reference.  The RSO will review the sheet(s) periodically to ensure that inventory records are being properly maintained.  When all of the material has been used or when the remaining material is surrendered to Radiation Safety staff, the inventory sheet must be returned to the EHSS. Upon its return, the material referenced on the sheet will be deleted from the RMS’s possession and an out of inventory date will be entered into the database.  Returned inventory sheets will be maintained by EHSS for a period of 7 years.

2.5  Procedures for Ordering Radioactive Material

(i) General Purchase Requisitions

All purchase requests for radioactive material must be approved by the Radiation Safety staff. It is the obligation of the Radiation Safety staff to assure that all purchases of radioactive materials are for authorized radioactive materials and within the possession limits of the University’s License. To ensure this requirement, the following procedure must be followed: (specific details for requisitions for standing orders of radioactive material are provided in Section 2.5.2):

  1. All purchase requests for radioactive materials must identify the purchase as “Radioactive Materials” by noting this in capital letters on the purchase requisition.
  2. The purchase requisition must be sent to the Environmental Health and Safety Service Office, 029 Lyman Hall, Attention: Radiation Safety Officer. The purchase request must contain:
    1. Isotope identity
    2. Compound/chemical form
    3. Activity requested
    4. Vendor
    5. Signature of the Radioactive Materials Supervisor
  3. The purchase requisition is reviewed and then processed in the following manner by Radiation Safety staff:
    1. The requesting supervisor’s authorization and possession limits are checked to ensure that the supervisor is approved to possess the type and quantity of material requested for purchase.
    2. If the request is not within the authorization limits, it is returned to the RMS.
    3. If the request is within the authorization limits:
      1. The requisition is stamped to indicate to Purchasing personnel that the request is allowed for purchase.
      2. The purchase requisition is checked to ensure all of the appropriate information has been provided and that it indicates that packages should be delivered to:

        Environmental Health and Safety Service Office
        029 Lyman Hall
        100 College Place
        Syracuse, NY 13244

      3. RSO or his delegate then signs and dates the requisition and forwards it to Pre-Audit for approval
      4. Pre-Audit forwards the requisition to Purchasing for processing

      Note: Purchasing personnel will not process any request for radioactive materials without prior approval from the RSO or designee.

    4. Approved purchase requests are assigned an inventory number at the time of approval for purchase. The inventory number, RMS and specific information regarding the purchase are then logged into the “Receiving Log Book”.
      The following information must be recorded:

      1. Inventory number
      2. Isotope
      3. Activity and calibration date
      4. Form
      5. Vendor
      6. Radiation Materials Supervisor’s name
      7. Storage location
      8. P.O. number
    5. Once the requisition is processed by Purchasing, Purchasing contacts EHSS with the purchase order number and any pertinent delivery information. A copy of the purchase requisition is returned to the Environmental Health Office with the assigned purchase order number.
    6. Upon delivery of the purchase to EHSS, the package is surveyed appropriately by Radiation Safety staff. The results of the survey and the receiving information are logged in the “Receiving Log Book”.

      Note: Deliveries are accepted only during normal working hours.

    7. The package is delivered to the laboratory by Radiation Safety staff.

(ii) Standing Order Purchase Requisitions 

All purchase requests for standing orders of radioactive material must be approved by the RSO. It is the obligation of the Radiation Safety Officer to assure that all purchases of radioactive material are for authorized radioactive materials and within the possession limits of the License. To ensure this requirement, the following procedure must be followed when establishing a Standing Purchase Order for radioactive materials:

  1. Standing order purchase requisitions for radioactive materials must identify the purchase as “Radioactive Materials Standing Order” by noting this in capital letters on the purchase requisition.
  2. The purchase requisitions must be sent to the Environmental Health and Safety Service Office, 029 Lyman Hall, Attention: Radiation Safety Officer. The purchase request must contain:
    1. Isotope(s) identity
    2. Compound(s)
    3. Activity(s) requested
    4. Supplier
    5. Signature of the Radiation Materials Supervisor
    6. “Orders to be telephoned in as needed”
  3. The purchase requisition is reviewed and then processed in the following manner by the RSO or his delegate:
    1. The supervisor’s authorization and possession limit are checked to ensure that the supervisor is approved to possess the type of material and quantity of each item listed on the order.
    2. If the request is not within the authorization limits, it is returned to the RMS.
    3. If the request is within the authorization limits:
        1. The requisition is stamped to indicate to Purchasing personnel that the request is allowed for purchase.
        2. The purchase requisition is checked to ensure all of the appropriate information has been provided and that it indicates that packages should be delivered to:

      Environmental Health and Safety Service Office
      029 Lyman Hall
      100 College Place
      Syracuse, NY 13244

      1. RSO or his delegate then signs and dates the requisition and forwards it to Pre-Audit for account approval.
      2. Pre-Audit forwards the requisition to Purchasing for processing

      Note: Purchasing personnel will not process any request for radioactive materials without prior approval from the RSO or designee.

    4. No information is entered into the receiving log and no inventory numbers are assigned until a telephone order is placed by the requesting laboratory.
    5. Upon processing by Purchasing, a copy of the purchase requisition is returned to EHSS with the assigned purchase order number.
    6. Telephone request sheets are then filled out by Radiation Safety staff (one sheet for each item/quantity ordered). These request sheets are sent to the labs for completion at the time the actual order is placed.
    7. Laboratory personnel must contact the Radiation Safety staff prior to placing each telephone order. Radiation Safety staff will verify that the order will be within the RMS’s possession limit and enter the specific information regarding the purchase in the Receiving Log. An order that will cause a possession limit to be exceeded will not be approved for purchase.

2.6 Active Use of Storage

Radioactive materials may be stored only in areas which have been approved by the Radiation Safety Officer.  The RSO must be kept informed of all changes in storage or use areas and will provide assistance in the selection of these areas as necessary to ensure compliance with NYSDOH regulations. Food, drink, tobacco, and/or cosmetics must not be stored or used in the same area as radioactive material.

Radioactive material storage/use areas must be chosen to minimize the probability of the radioactive material being involved in an explosion, fire, or flood.  These areas must be shielded, as necessary, to ensure that the sources do not cause the dose in any unrestricted area to exceed 2 mrem in any one hour and do not result in a total effective dose equivalent to any non-occupationally exposed individual in excess of the 100 mrem in a year.

In addition, radioactive material use and storage areas must be labeled in accordance with 10 NYCRR Part 16.12 and Section 6 of this Handbook. All storage and use areas must be kept secured at all times when not in direct attendance by an authorized radioactive material user, to prevent the unauthorized removal of radioactive material. Radioactive liquids must be stored in non-breakable, sealable containers and be provided with secondary containment capable of holding the contents of the primary vessel. Volatile radioisotopes must be stored in fume hoods or other exhausted locations or in frozen solutions.

The RSO must be notified immediately upon discovery of a lost, missing or stolen source so that appropriate steps can be taken.

2.7 Transporting/Shipping Radioactive Materials

(i) Transporting Radioactive Materials on Campus

Laboratories may occasionally need to move radioactive materials outside of approved use areas through non-controlled areas (i.e. hallways, campus sidewalk).  This type of transport may only be performed when authorized by the RSO or RSC.  Authorization may be obtained by indicating the need to perform such transport in the supervisor’s “Application for Use of Radioactive Material” or by submitting a request in writing to the RSO/RSC for approval.  All requests for transport outside of controlled areas must be accompanied by a transport protocol specific to the situation.  The following is provided as a guide to aid in developing transport protocols:

  • Containers should be chosen to ensure no loss of material even in unusual circumstances. Three layers of containment (tertiary containment) are required for non‑sealed radioactive material (primary vessel plus two other non-breakable vessels). One containment vessel may be sufficient for some sealed sources.
  • The dose at the surface of the outer container must be limited to a maximum of 2 mrem in any one hour and must not result in a total effective dose equivalent in excess of 0.5 mrem to any non-occupationally exposed individual. These limits may be met by increasing the size of the container and/or adding additional shielding.
  • The outer container must be labeled as specified in Part 6 of this Handbook.
  • The outer container must be wipe tested to demonstrate surface contamination levels below the limits listed in Section 2.9.4 of this Handbook.
  • The move must be accomplished safely and only by approved radiation workers.
  • The container must not be left unattended while it is outside of a controlled area.

Radiation Safety staff will provide assistance with any transportation questions or concerns.

(ii) Transporting/Shipping Radioactive Materials Off Campus

The US Department of Transportation (DOT) has specific packaging and shipping requirements for DOT Class 7 radioactive materials. The US DOT mandates training for individuals who directly affect the shipment of hazardous materials including individuals who prepare shipments, complete (sign) shipping documents and/or shippers of class 7 radioactive materials. The transport of radioactive materials over private and public streets and highways must be done in accordance with State and Federal regulations (this includes transportation by the US mail, common carriers, or an individual). In certain circumstances, the US DOT also requires that a Transport Security Plan be developed and implemented.

All transport or shipment of radioactive materials must be approved by the RSO or delegate prior to commencement to help ensure compliance with applicable regulations, including training, packaging and security requirements. Individual’s proposing to ship/transport radioactive material off-campus or requesting radioactive material be shipped to them, must review the proposed shipment with the RSO before any shipment is arranged. These individuals must also follow the procedure for the transfer of radioactive materials to/from an off-campus location provided in Section 2.8.2 of this Handbook. This procedure will to help ensure accuracy in inventory records and compliance with the University’s licensed possession limits.

2.8 The Transfer of Radioactive Materials

Syracuse University Approved RMSs may transfer radioactive material to/from another approved institution or another Syracuse University supervisor only with approval of the RSO.  Procedures for transferring radioactive material between Syracuse University RMSs or to/from another institution are provided in this Section.  These procedures must be followed to ensure that the University is aware of those individuals who have radioactive material for which the University is responsible and that the proper documentation has been maintained.  Once a transfer has been approved, the actual movement or shipment of the radioactive material must be done in accordance with applicable regulations and Section 2.7 of this Handbook.

(i) Transfers Between Syracuse University Approved Radiation Supervisors

The following procedure must be followed when transferring radioactive materials between approved RMSs at Syracuse University:

  1. The RMS releasing the material must complete the “Transfer of Radioactive Material Form” including:
  1. All of the “Materials Transferred Section”
  2. Releasing RMS information
  3. Receiving RMS information
  1. Send or deliver the transfer form to the RSO.
  2. Radiation Safety staff will verify that the receiving RMS is authorized to posses the material to be transferred.
  3. If the receiving RMS is not authorized to possess the transfer material, Radiation Safety staff will notify both labs that the transfer cannot occur.If the receiving RMS is authorized, the releasing RMS is responsible for the proper packaging and transfer of the material.
  4. If the receiving RMS is authorized, the releasing RMS is responsible for the proper packaging and transfer of the material.The releasing RMS must indicate on the material’s original inventory sheet, the amount and date of transferred material.
  5. The releasing RMS must indicate on the material’s original inventory sheet, the amount and date of transferred material.
  6. Radiation Safety staff will assign the transferred material a new inventory number and inventory sheet. This inventory sheet must be maintained by the receiving RMS.

(ii) Transfer To/From Another Institution

The institution receiving/shipping the radioactive material must provide proof of their authorization to receive the material.  This proof must be in the form of a radioactive material license or certificate of registration.  The following procedure must be followed when transferring radioactive material between an approved radioactive material supervisor at Syracuse University and another institution: 

  1. Supervisor releasing/receiving the material must complete the “Transfer of Radioactive Materials Form”  including:
    1. All of the ‘Materials Transferred Section”
    2. Releasing RMS/Institute information
    3. Receiving RMS/ Institute information
  1. The transfer form must be delivered or sent to the RSO.
  2. Radiation Safety staff will verify that the receiving institute or RMS is licensed to receive the transfer material and notify the Releasing RMS/Institute
  3. The material to be transferred must meet all appropriate packaging, training, shipping, and transport regulations as specified by the US Department of Transportation in 49 CFR Part 173. The Syracuse University RMS involved in the transfer is responsible for the costs associated with the actual transfer of the material.
  4. All material transferred onto campus must be delivered directly to the Radiation Safety Laboratory. Radiation Safety staff will perform the required surveys and assign the material an inventory number and inventory sheet. The inventory sheet must be maintained by the Syracuse University RMS receiving the material.

2.9 Surveys and Inspections of Radioactive Material Use Areas and Equipment

Radioactive contamination is the presence of radioactive material in undesirable locations. Radioactive contamination is a potential health hazard since it can be a source of internal and/or external exposures.  It may be easily spread throughout a facility, jeopardizing the success and accuracy of experiments.   Although the use of good laboratory organization and operating procedures can help to minimize radioactive contamination, the potential for contamination still exists. Radiation area surveys are an effective way of locating radioactive contamination and confirming that contaminated areas are effectively remediated.

Laboratories which use or store radioactive materials must implement contamination control and ambient radiation exposure monitoring surveys. The purpose of these surveys is to identify and limit the spread of radioactive contamination and to ensure that radiation levels in the laboratory are kept as low as reasonably achievable. In addition, Radiation Safety staff will periodically perform air monitoring in laboratories where there is a reasonable expectation for airborne contaminants.

Records of all radiation surveys must be maintained for a minimum of three years.

(i) Removable Contamination Surveys

Removable contamination is radioactive contamination that can be removed from the contaminated surface.  A wipe test is the accepted method for removable surface contamination monitoring.  A wipe test (a.k.a. swipe or smear) is performed by rubbing a cloth filter paper or similar material over the surface (100 cm2) of the object/area being tested.  The “wipe” is then analyzed to determine if removable radioactive contamination is present on the object/area wiped.

Laboratories containing unsealed radioactive materials are required to monitor for removable surface contamination.

Monthly Comprehensive Survey

All laboratories which use and/or store unsealed radioactive materials must perform a monthly removable contamination survey. The monthly survey is a comprehensive survey of the laboratory encompassing all areas and equipment that come in contact or have the potential to become contaminated with radioactive materials.  The monthly survey sites are generally pre-characterized by Radiation Safety staff and must include:

  • All radioactive use and storage areas (benches, equipment, sinks, etc.)
  • All radioactive waste storage locations
  • Adjacent non-controlled areas (floors, benches)

Monthly surveys must be submitted to Radiation Safety staff on or about the last day of each month for analysis.

Limited Weekly Survey

A weekly removable contamination survey must be performed in laboratories for each week in which a single use of open source radioactive material exceeds 250 uCi (exclusive of stock container extractions of less than 250 uCi).   The performance of weekly wipe tests may be limited to those sites where quantities in excess of the threshold level (250 uCi) are used.  The sites may include all or a portion of the sites tested in the comprehensive monthly survey and may change from week to week depending on usage in the laboratory.  Weekly surveys must be submitted to Radiation Safety staff on or about the last working day of the week for each week in which they are required.  If only one use of 250 uCi or more is anticipated during any one working week, it is recommended that the weekly wipe survey be performed immediately following that use.

For all removable contamination surveys, the analysis of the wipe tests must be, at a minimum, sensitive enough to detect the removable contamination action level indicated in Section 2.9.4. for contaminant(s) involved.  The preferable method for counting the wipe tests is liquid scintillation counting (for beta and low energy gamma emitters).  All other counting methods used for analysis of the wipe tests must be approved by Radiation Safety staff prior to use.  It is recommended that the analysis of the wipe tests be performed by Radiation Safety staff as part of the Removable Contamination Survey Analysis Program (see Section 2.9.2).

A permanent record of each contamination survey, including negative results as numerical values, must be maintained and must include:

  • A cover sheet indicating the time period for the survey (i.e. month of), the name of person conducting the survey and the date conducted.
  • A drawing of the area surveyed indicating relevant features of the area, including all radioactive use areas and equipment, and identifying and coordinating all survey site locations and survey results.
  • Information on the analysis method used including equipment manufacturer, model number, etc. and pertinent counting efficiencies.
  • Analysis results in dpm/100 cm2
  • Remediation actions and post remediation results

(ii) Removable Contamination Survey Analysis Program

The Environmental Health and Safety Service Office offers a program for the analysis of removable contamination wipe tests.  Laboratories are encouraged to take part in this program to ensure appropriate analysis of the wipe tests. In the program, wipe tests of pre-characterized sites are performed by laboratory personnel and sent to Radiation Safety staff for analysis. Monthly surveys must be performed and sent on or about the last day of each month and weekly surveys must be performed and sent on or about the last working day of the week for each week in which they are required. Radiation Safety staff perform the analysis of the wipes and generate a result sheet with corresponding wipe site locations. The results are returned to the laboratory along with a request for remediation of areas in excess of the removable contamination limits (Section 2.9.4).

(iii) Area Surveys

Radioactive use areas must be surveyed for contamination after each use of radioactive material. All work areas and equipment used in conjunction with radioactive material must be surveyed with a meter appropriate to detect the type of radiation used. Survey results in excess of limits established in Section 2.9.4 should be immediately remediated.

(iv) Surface Contamination Remediation Action Levels

Action must be taken to eliminate surface contamination when the levels of contamination exceed the limits listed on the “Surface Contamination Limits” Table below. Total activity refers to all detectable emissions from a surface.  Removable contamination is defined in Section 2.9.1 of this Handbook.

Surface Contamination Limits
*adapted from 10 NYCRR Part 16 appendix 16A, Table 7
Alpha
Beta/Gamma3
Radioiodines4
Application
Total
dpm
100cm2
Removable
dpm
100cm2
Total1
mR/hr
Removable
dpm
100cm2
Total
mR/hr
Removable
dpm
100cm2
Controlled areas
· Work area 1000 200 0.5 1000 0.1 200
· Clean area 500 100 0.1 500 0.02 20
Non-controlled areas
· Skin and personal objects ND2 ND2 ND2 ND2 ND2 ND2
· Object removed from controlled area 200 50 0.1 500 0.02 20
· Release of facilities 200 50 0.1 500 0.02 20

1 Measured at 1cm from surface

2 ND= Non-detectable

3 Except special nuclear material, transuranics, natural uranium

4 Radioiodines include all radioactive Iodine isotopes ( i.e. I124, I131, I129, etc.)

(v) Ambient Radiation Monitoring

Ambient radiation monitoring is the measurement of radiation exposure at various locations in the laboratory. Monthly monitoring  is required to be  performed in all laboratories or areas containing 200 uCi or more of radioactive materials (not including H3, S35, Tc99 and C14). The measurements must be performed with a survey meter sensitive enough  to detect 0.1 mR/hr.

Ambient exposure measurements must be taken at locations which are representative of areas where exposures are likely to occur. The survey locations must be indicated on a site map, repeated from Month to Month and include the following:

  • Active source storage locations
  • All radioactive use areas
  • Radioactive waste storage locations

Exposure measurements, in mR/hr, should be logged onto the “Ambient Exposure” form with corresponding site locations.  Permanent records of ambient exposure surveys must maintained in the laboratory.  The survey records, which will be reviewed periodically by the RSO, must include:

  • Location, date performed, identification of equipment used, (manufacturer, model number, detector model number, etc.) and pertinent counting efficiencies
  • Name of person conducting the survey
  • Drawing of area surveyed, identifying and coordinating survey site locations and survey results
  • Background radiation measurement
  • Net results in mR/hr
  • Remediation actions and post remediation results

An action level of 0.5 mR/hr has been established for ambient exposures. Measurements at any site greater than 0.5 mR/hr require remediation. Remediation actions may include:

  • Returning unshielded source(s) to shielded storage area
  • Adding shielding around a radiation source
  • Removing contamination causing radiation exposure, etc.

Post remediation survey measurements and the method(s) of remediation must be documented in the  permanent ambient radiation monitoring record.

(vi) Laboratory Air Sampling

Periodic air sampling will be performed in the laboratories pursuant to NYSDEC and NYSDOH regulations and as deemed necessary by the RSO. The air sampling will be performed by Radiation Safety staff and will be appropriate for the type and form of potential airborne contamination in the area and/or effluent.  In addition, if personnel have a potential for exposure to airborne radioactivity, an evaluation may be performed.

(vii) Miscellaneous Surveys

Protective devices such as fume hoods, filters, lead lined aprons and gloves, and interlocks must be maintained in good repair and proper operating condition.  These devices must be inspected at intervals specified in the regulations and/or as directed by the RSO.

(viii) Semi-Annual Laboratory Inspections

Radiation Safety staff will perform a complete inspection of all radioactive material use laboratories twice a year.  Each laboratory will be notified approximately one  month in advance of the impending inspection and provided with a pre-inspection checklist. The inspection will include removable contamination wipe testing, gross contamination surveys, a laboratory operations review, a review of required radiation records, etc.  A summary of the results of the inspection will be provided in writing to the laboratory supervisor.  The inspection summary will inform the supervisor of the inspection results including cited infractions and the associated classification and severity level of each. Remedial action(s) to correct an infraction(s) must be taken as soon as practicable and submitted in writing, as indicated in the summary, to the RSO.  Enforcement action(s) imposed for cited infractions will be determined by the RSO/RSC, based on the University’s Radiation Infraction Enforcement Policy (Section 2.15).

2.10 Radioisotope Laboratory Guidelines – Rules for the Safe Use of Radioactive Material in Laboratories

Contamination control is an essential part of working with radioactive material. External and internal radiation exposure can be minimized by careful planning and good judgment. The following is a list of “Rules for the Safe Use of Radioactive Materials in Laboratories”.  These rules must be posted conspicuously in each laboratory where radioactive materials are used and each radiation supervisor and radiation worker must be familiar with them.

  1. Wear laboratory coats or other protective clothing at all times in areas where radioactive materials are used.
  1. Wear appropriate, disposable gloves at all times while handling radioactive material.
  1. Properly monitor hands and clothing and all areas after each use of radioactive materials or before leaving the controlled area.
  1. Do not eat, drink, smoke, or apply cosmetics in any area where radioactive materials are used or in areas where radioactive materials are stored.

(b). Do not store food, drink, or personal effects with radioactive material or in areas where radioactive materials are used.

  1. Wear appropriate personnel monitoring devices at all times while in areas where radioactive materials are used or stored. These devices should be worn appropriately. (Whole body monitors at the chest level; extremity monitors where highest exposure is likely to occur.)

(b). Personnel monitoring devices, when not being used to monitor occupational exposures, must be stored in a central designated low background area.

  1. Dispose of radioactive waste only in specially designated and properly shielded receptacles.
  1. Never pipette by mouth; never cross contaminate pipettes. Pipettes used for radioactive materials should not be used with non-radioactive materials.
  1. Confine radioactive solutions in covered containers plainly labeled with the name of the compound, radionuclide, date, activity, and radiation level, if applicable.
  1. Work should be planned ahead whenever possible. A dry run using non-radioactive materials should be made to test the procedure.
  2. The laboratory should be kept neat and clean. Equipment or material not being used should be stored in a place away from the work area.
  1. Radioactive materials must be labeled as indicated in Section 6 of this Handbook.
  1. Caution and other warning signs must be posted as described in Section 6 of this Handbook and must not be removed without proper authority. Articles labeled with a radioactive warning sign cannot be disposed of without the consent of the RSO.
  1. Radioactive material in liquid form must be transported in sealable tertiary containment (3 containers) which will retain their integrity when dropped.
  1. All injuries and contaminations in areas containing radioactive materials, no matter how minor, must be reported to the lab’s RMS as soon as possible.
  1. An Emergency Procedure relating to the work performed in the laboratory must be posted and its contents made known to all individuals in the laboratory. The procedure must include the names and telephone numbers of all personnel to be contacted in case of an emergency.
  1. The location and operation of emergency equipment (i.e. fire extinguishers, safety showers) must be familiar to all laboratory employees.
  1. All equipment intended to provide features of safety must be evaluated periodically to ensure that they are providing the safety features intended.
  1. Flammable liquids such as ether, benzene, or acetone must be segregated as much as possible away from stored radioactive materials.
  1. Pressure bottles or tanks containing gas must be secured to the wall, bench, floor, or other rigid objects.
  1. All items coming into contact with unsealed radioactive material must be checked, and cleaned as necessary, to ensure levels of contamination are below those listed in Section 2.9.4, before the items are used in other work.
  1. Floors, benches and other surfaces in unsealed radioisotope work areas must be smooth, non‑porous, and easily decontaminated. Manipulations of unsealed radioactive material must be carried out on a double layer  of absorbent paper backed by plastic. The use of edged trays is encouraged.
  1. All work involving volatile radioisotopes or which may generate airborne radioactive particles or vapors should be done in a fume hood which as been approved for radioisotope use.
  1. Re-capping needles used in conjunction with radioactive materials without the use of a capping block or other approved method, is strictly prohibited.

2.11 Equipment Calibrations

(i) Survey Instrument Calibration

Monitoring equipment must be routinely calibrated against standard radiation fields to determine the equipment’s detection efficiency. Survey instruments will be calibrated annually by Radiation Safety staff. Survey instruments with scales in mR/hr and CPM will be calibrated for count rate (CPM) only.  A calibration sticker will be placed on each instrument following the calibration indicating:

  • Calibration date
  • Calibration source
  • Battery and speaker check results
  • Calibration angle
  • Instrument’s efficiency for various isotopes
  • Correction factor for each scale calibrated (for converting the CPM to mR/hr)

New survey meters must be registered with and calibrated by the Radiation Safety staff prior to use.  Standard sources of various radioisotopes are available from the RSO for calibration of other detection systems.

(ii) Quantitative Measuring Equipment Calibration

Instruments used for quantitative measurement must be calibrated at least every six (6) months.  This includes liquid scintillation counters and other equipment used to quantify radioactive material.  All calibrations must be performed with sources appropriate to the material to be quantified (i.e. sources with similar energy and type of radiation).

(iii) Survey Instrument Calibration Documentation

Documentation of all radiation instrumentation calibrations must be maintained for a minimum of 5 years and must include:

  • The owner/user of the equipment
  • A description of the equipment (i.e. manufacturer, model, serial number)
  • A description of the calibration source(s)
  • The calculated and actual exposure rate at each calibration point
  • Battery check reading (if applicable)
  • The angle between the radiation flux field and the detector (parallel or perpendicular for external detectors and the angle for internal detectors)
  • Calibration results, correction factors, efficiencies
  • The name of the person who performed the calibration and the date the calibration was performed

2.12 Radioactive Sealed Sources

A sealed source is a source of radioactive material that is permanently bonded or fixed in a capsule or matrix. The capsule or matrix must be designed to prevent the release and dispersion of the radioactive material during conditions which are likely to be encountered in normal use and handling. Sealed sources are generally used for didactic purposes, as reference standards and in devices such as gas chromatographs, ionizing chambers, and sample irradiators.

(i) Use, Possession, and Control of Sealed Sources

The use of and possession of sealed sources is governed by the Radiation Safety Committee. Individuals wishing to be authorized to possess and use or direct the use of a radioactive sealed source(s) must submit an “Application to Use Radioactive Material” with the RSC via the RSO.  Individuals working with sealed sources under the direction of a Radioactive Materials Supervisor must complete the radiation worker training program.

Sealed sources must be properly labeled, shielded, and secured from unauthorized removal at all times.  A sealed source(s) may be assigned to an single authorized Radioactive Materials Supervisor.   This RMS is responsible for this source and its use.  If  a source or sources are shared by two or more authorized RMS or if they are collectively stored in a central location, a Sealed Source Custodian must be assigned to the sources.  This individual is responsible for properly securing and shielding the source(s) when in storage. Individual uses of the source(s), however, are always the responsibility of the RMS and must be done in accordance with RSC approval.

The Sealed Source Custodian/RMS must log the date and time of the removal and return of all sources used in the sealed source log assigned to the particular area. Also included in this log should be the name of the authorized individual removing the source and the location of use of the source.  The Sealed Source Custodian/RMS may release a source only to an authorized RMS or an authorized Radioactive Materials Worker.  All sources should be returned to storage on the same day they are removed. If sources are to be removed from storage for longer periods of time, the Radioactive Materials Supervisor is responsible for properly shielding and securing the source from ANY AND ALL unauthorized removal. Sources unexpectedly not returned to the Sealed Source Custodian/RMS must be immediately reported to the RSO as missing.

(ii) Handling Sealed Sources

All sealed sources greater than 100 mR/hr at the surface must be handled with remote handling devices. All other sealed sources should be handled with remote handling devices whenever possible to reduce individual exposure. Sealed sources must be shielded when not in active use to 2 mR/hr or less at the outside surface of the shield.  This shielding must also be sufficient to ensure that the exposure in any unrestricted area  does not exceed 2 mrem in any one hour and does not result in a total effective dose equivalent  to any non-occupationally exposed individual in excess of the 100 mrem in a year.

Sealed sources cannot be opened or altered in any way. Care must be taken not to rupture thin windows covering some types of source material. If a sealed source is found to be dented, ripped, altered or compromised in any fashion, the RSO must be notified immediately.

(iii) Leak Testing of Sealed Sources

Periodic leak tests are required on sealed sources containing radioisotopes other than tritium, with a half-life of more than thirty days, in a form other than gas. Beta and/or gamma emitting sources containing less than 100 microcuries of activity are also exempt from this leak testing requirement.   The testing interval for all other sources in use must not exceed three months for alpha emitting sources and six months for beta/gamma emitting sources. Leak testing of sealed sources will be performed on a regular basis by Radiation Safety staff.

All sources, including those exempt from the leak testing requirements, must be inventoried every three months.  The Sealed Source Custodian/RMS is responsible for performing and documenting the inventory of all sources in his/her custody at least quarterly. This inventory should indicate the source, the date, the location of the source and the name of the person conducting the inventory.

(iv) Sealed Source User Training

Syracuse University requires that anyone who wishes to use radioactive sealed sources have a thorough understanding of regulations and hazards associated with the use of ionizing radiation. This is accomplished through a sealed source user training program which includes a series of videotapes and a class room lecture.   The training program, which is provided by Radiation Safety staff, must be completed prior to handling any radioactive sealed sources. Upon the successful completion of the training requirements an individual will be approved to use radioactive sealed sources under the direction of a sealed source supervisor.  A sealed source laboratory orientation form must be completed with the sealed source supervisor and returned to the RSO for review prior to commencing unsupervised source use. Dosimetry will be issued to monitor external radiation exposure (as applicable). For more information regarding the sealed source training or to sign up to the next sealed source user lecture, contact Radiation Safety staff at x-9130.

2.13 Use of Radioactive Materials in Vertebrate Animals

The handling, housing, and care of vertebrate animals used in conjunction with radioactive materials requires special consideration. Any procedure involving the use of radioactive materials in vertebrate animals must be approved, prior to commencement, by the RSC and the Institutional Animal Care and Use Committee.

(i) Housing and Care of Radioactive Animals*

(*Vertebrate Animals Only)

Radiation exposure to animal handlers and other individuals who may frequent the area can occur from direct radiation exposure, exposure to airborne radioactive contaminants from the exhalation of metabolized radioactive compounds or from exposure to contaminated animal wastes, bedding or cages. To reduce this exposure to humans, the following guidelines have been established:

  1. All radioactive animals and associated caging or housing must be segregated from the housing of other animals.
  1. All caging or housing containing radioactive animals must be labeled with a “Caution Radioactive Animals” or “Caution ­Radioactive Materials” sign. The housing must also be labeled with the following information:
  • Radioisotope used
  • Amount of radioactive material used per animal
  • Date of administration
  • Exposure rate at outside surface of cage (if applicable)
  • Number of animals occupying the cage
  • Principle Investigator’s name and emergency phone number(s)
  1. If contamination from excretion or exhalation from the animal is likely to be encountered, the use of metabolic‑type cages or other appropriate housing may be required.
  1. If airborne radioactive contaminants are likely to be produced by the animal, a mechanism to capture and exhaust these contaminants should be available. The housing should contain a label indicating this hazard.
  1. Animal excretion from radioactive animals must be collected and properly disposed of as radioactive waste. Excretion mixed with sawdust, wood shavings or other bedding may be collected in plastic bags, sealed, and placed in appropriate containers supplied by the Radiation Safety Office. Activity levels must be properly tallied and maintained. Liquid wastes may be disposed via the sanitary sewer system, but appropriate records must be maintained if this disposal method is used (see Sewer Disposal Requirements Section 3.4.1).
  1. Animal handlers must be instructed by the responsible investigator as to the handling and care requirements of the radioactive animals and animal wastes in each and every case. The Principal investigator is also responsible for maintaining all required documentation.
  1. When housing has been vacated by the radioactive animal, a proper survey and/or wipe test(s) must be performed and documented to demonstrate that the cage is free of radioactivity. Once free of radioactive contamination, the labels must be removed and properly defaced.
  1. The rules, guidelines, and general provisions for work with unsealed radioactive sources should be followed where applicable.

(ii) Inspection and Dissection of Vertebrate Animals

The injection of radioactive materials into vertebrate animals and dissection of such animals must be performed in trays lined with absorbent material. Where trays are inappropriate, surfaces should be lined with plastic backed absorbent paper. Protective gloves and clothing must be worn by all associated personnel during these procedures. Individuals and the use area should be appropriately monitored after each procedure. If materials are found to be contaminated, they must be decontaminated or dealt with as radioactive waste.

(iii) Disposal of Radioactive Carcasses and Wastes

Radioactive animal carcasses, excretion, and bedding must be properly labeled and handled as radioactive wastes. The labeling and handling requirements and procedures are outlined in Section 3.2.5 of this Handbook.

2.14 Decommissioning and Vacating Controlled Areas

Once an area has been designated as a controlled area for the use of radioactive material by the RSC, it shall remain so until it has been found suitable for non-radioactive uses and released by Radiation Safety staff.  Radiation Safety staff will direct the close-out procedure performed by the vacating RMS and will also independently verify the results. Signs identifying  radioactive material storage and work areas must not be removed until authorized by Radiation Safety staff. Equipment which was designated and labeled for use in conjunction with radioactive materials must also remain labeled until surveyed and released by Radiation Safety staff. The limits for radioactive surface contamination for the release of facilities are provided in Section 2.9.4 of this Handbook.

It is the obligation of the Radioactive Materials Supervisor to notify the RSO, in writing, 60 days in advance of the intended date to vacate. 

Radiation Safety staff will retain site maps of all current and previous controlled radiation areas and records of all decommissioning activities until disposal is authorized by NYSDOH.

2.15 Enforcement Policy for Radiation Safety Interactions

The Radiation Protection Program Enforcement Policy is designed to inform University radiation supervisors of the sanctions that may be imposed for various radiation safety infractions cited during radiation laboratory inspections (i.e. semi-annual inspections, laboratory visits, informal investigations, etc.). The Policy will assist Radiation Safety staff in uniformly assigning enforcement actions to the infractions identified.  The Policy was is based on Nuclear Regulatory Commission guidance.

(i) Identification of Infractions

When a radiation safety infraction is identified by Radiation Safety staff during a laboratory inspection the infraction is noted on the inspection form.  If the infraction poses an immediate risk to health, safety or the environment or a potentially imminent health hazard, appropriate action(s) will be taken immediately to control or eliminate the hazard/risk.  These actions may include cessation of radioactive material activities, restricting access to the laboratory, locking out the power supply to radiation producing equipment, etc.  Examples of imminent hazards/risks include, but are not limited to: a lost or missing radioactive source, extensive amounts of contamination, excessive exposures, and malfunctioning radiation producing equipment.

If no imminent hazard/risk is posed, the infraction will be discussed with the laboratory supervisor and/or other laboratory personnel, as appropriate, at the completion of the inspection. Formal notification of the inspection findings will be provided to the laboratory’s supervisor in the inspection summary sent by Radiation Safety staff.

(ii) Infraction Notification

Following each laboratory’s radiation safety inspection, an inspection summary will be sent to the laboratory’s supervisor.  The inspection summary will indicate the infraction(s) found during the inspection and the associated enforcement classification and severity level(s), as well as recommendations regarding radiation use in the laboratory. The inspection summary will request the supervisor to remediate the infraction(s) and notify the RSO in writing, when applicable, of the corrective action(s) taken.  Corrective actions taken at the time of the inspection will be noted on the inspection summary and no further action will generally be required.  Supervisors will be notified during the inspection of situations found which require immediate action.  If required, laboratory operations will be interrupted until the infraction(s) is corrected.

(iii) Types of Infractions

For the purpose of this enforcement policy, infractions are classified into two groups: violations and deviations.  The infraction’s classification will be noted on the inspection form and on the supervisor’s inspection summary.

  • Violation: A violation is a failure to comply with a regulatory requirement such as a rule, regulation or license condition.
  • Deviation: A deviation is a failure to satisfy a written commitment (i.e. the supervisor’s “Application for use of Radiation”), a program requirement, or a Radiation Safety staff directive.

(iv) Severity Levels

Once the infraction has been classified as a deviation or violation, its level of severity is determined.  The severity level will be assigned, at the discretion of Radiation Safety staff, based on the safety significance of the infraction.  Six severity levels have been established in this Enforcement Policy, with Level I being the most serious, and Level VI being the least serious.

  • Level I: The highest level of severity.  Results from a violation that is reportable to a regulatory agency having jurisdiction (i.e. NYSDOH, NYSDEC, USEPA, etc.) and causes an immediate/high risk to safety, health or the environment, and/or a potential action against the University’s Radioactive Material License.
  • Level II: A serious infraction that presents immediate/high risk to safety, health or the environment, and/or a potential action against the University’s Radioactive Material License, but is not reportable to a regulatory agency having jurisdiction.
  • Level III: A serious infraction that presents a significant risk to health, safety and/or the environment.
  • Level IV: A less serious infraction, that presents a minimal to moderate risk to health, safety and/or the environment.
  • Level V: A minor infraction, typically a record keeping issue, that presents a minimal risk to health, safety and/or the environment.
  • Level VI: Generally not a regulatory related issue, but one to which a modification is recommended and/or required.

(v) Enforcement Actions

The imposed enforcement action(s) will be determined based on the classification of infraction (i.e. violation or deviation) and its assigned level of severity.  The Enforcement Table will be used as a guide for determining the appropriate enforcement action(s).  The Enforcement Table provides typical actions which may be imposed, at the discretion of the Radiation Safety Officer and/or the Radiation Safety Committee, for cited infractions. This Table is not meant to be all inclusive and other actions may be imposed as necessary and/or appropriate.

Supervisors will be advised of the imposed enforcement action(s) in writing. Concerns, grievances, etc., regarding the inspection findings or imposed enforcement actions, will first be discussed with the Radiation Safety Officer. Unresolved issues will be submitted to and addressed by the Radiation Safety Committee.

(vi) Repetitive Infractions

A repetitive infraction is when the same infraction is noted during two consecutive inspections or when a similar infraction re-occurs because a previous infraction was not properly remediated.  The enforcement action(s) for a repetitive infraction will be based on the next higher severity level than used for the previously cited infraction.

(vii) Enforcement Action Table

This table lists only typical enforcement actions and is not meant to be an all-inclusive list. The actual enforcement action(s) imposed will not be limited to this table.

Severity Violation Deviation
I
 ·      Immediate suspension of laboratory operations
II
 ·      Suspension of Activities

·      Increased surveillance

·      Supervisor appears before RSC

·      Additional training

·      Department Head/Dean notified

 ·      Suspension of activities

·      Increased surveillance

·      Supervisor appears before RSC

·       Supervisor appears before RSC

·      Additional training

·      Department Head notified
III
 ·      Suspension of activities

·      Increased surveillance

·      Formal meeting with supervisor

·      Additional training

·      Department Head notified

 ·      Increased surveillance

·      Formal meeting with supervisor

·      Additional training

·      Department Head notified
IV
 ·      Increased surveillance

·      Formal meeting with supervisor

·      Additional training

·      Department Head notified

 ·      Increased surveillance

·      Discussion with supervisor

·      Additional training
V
 ·      Increased surveillance

·      Discussion with supervisor

·      Additional training

 ·      Discussion with supervisor

·      Additional training
VI
 Recommendation – generally no further action taken

Bold = Indicates written notification shall be provided to the RSO as to the corrective actions taken and/or planned.

Note: There cannot be a Level I Deviation since any infraction requiring notification to NYSDOH would be a violation.  There also cannot be a Level VI Violation, since a violation, by definition, is a regulatory issue.

< Previous Page | Next Page >