THE UNIVERSITY OF NEWCASTLE- DISCIPLINE OF MEDICAL BIOCHEMISTRY RADIATION LABORATORY

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1 THE UNIVERSITY OF NEWCASTLE- DISCIPLINE OF MEDICAL BIOCHEMISTRY RADIATION LABORATORY STANDARD OPERATING PROCEDURE PROCEDURE NO: BS-GDP 021 MOD: 3rd Issue Page: 1 of 12 Procedure Type: General Discipline Procedure 1. Purpose: 1.1 To provide information to new staff, students before commencement of work in the Radiation Laboratory LS Materials: 2.1 The following Compulsory Reading will be provided to new staff on commencement of employment: Induction Procedure (BS-GDP 001) Training Procedure (BS-GDP 002) Evacuation Procedure - Life Sciences (BS-GDP 005) 2.2 The following Compulsory Reading will be provided to new personnel requesting to use the Radiation Laboratory: GDP Radiation Safety GDP 008 Accessioning Radioactive Isotopes GDP 022 Radiation Laboratory Routine Procedures GDP 018 Radiation Laboratory Cleanup GDP 023 Radiation Laboratory Waste Disposal GDP 024 Wipe Test Method for Detecting Radioactive Contamination BS-BDP Along with the compulsory reading, you may also be directed to read a number of Procedures. 3. Set Up: 3.1 Log sheets, waste disposal forms and Hotlab Cleanup forms are kept in the New Forms Folder in the First Drawer of the Documents drawers in the Hot Lab. If the second last copy of the form is taken, please photocopy a new batch and place in the appropriate sleeve. WRITTEN BY CHECKED BY REVIEWED BY AUTHORISED BY NAME (signed) Lynn Herd Larisa Bobrovskaya Lynn Herd DATE 29 th April th April th March 2006 Distributed To: GDP Master File / GDP Lab File

2 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 2 of Isotope Logbooks are maintained for each different isotope that comes into the laboratory. Replace logbook when full and provide a new logbook if a new isotope is brought into the laboratory. 4. General Information 4.1 STANDARD OPERATING PROCEDURES A system of uniform documentation has been introduced into the Discipline of Medical Biochemistry in the form of Standard Operating Procedures (SOPs). There are several subcategories including: GDP - General Discipline Procedure GLP - General Laboratory Procedure GEP - General Equipment Procedure The SOP Master Folder is kept in room LS3-02 (Life Sciences), copies can be found in room LS3-26 and LS UNIVERSITY OF NEWCASTLE RADIATION SAFETY MANUAL Copy available in the Radiation Laboratory LS3-18 and on the web at RADIATION SAFETY COURSE The University Radiation Safety Officer in consultation with the Laboratory / Research Safety Officer organise for an outside company to provide an accredited Radiation Safety Course to University personnel and students who intend to work with Radioactivity. 4.4 RADIATION LICENCES / EXEMPTIONS Any person carrying out work with radioactive substances at the University is required to have a Radiation Licence to carry out such work; unless they have been issued with a formal exemption and are working under the direction and supervision of a person holding such a license. Exemption forms are specifically for students, and can be obtained from your Department Radiation Safety Officer. Applications for Radiation Licences may also be obtained from your Department Radiation Safety Officer. 4.5 REGISTRATION OF LABORATORIES All laboratories in which unsealed radioactive substances are used need to be

3 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 3 of 12 registered with the Department of Environmental Protection and Conservation, NSW. Appropriate registration information must be displayed on the laboratory door. LS3.18 Registration Number: year expiry. Nominated contact person for the premises: Dr David Kay 4.6 PROTECTIVE PERSONAL EQUIPMENT Lab coats, and enclosed shoes must be worn in the Radiation Lab at all times. A separate lab coat should be obtained for work in the Radiation Laboratory. This lab coat should remain in the Radiation Laboratory. Safety glasses should be worn when working with radiation, the only exception being when the radiation is shielded behind a perspex screen, thus providing a barrier between the eyes and the chemical source. Vinyl gloves are recommended for use with radioactive isotopes. When working with radiation it is recommended to double glove. In this way if the outer glove becomes contaminated, it can be removed and the hand is still protected. Lead aprons are also provided in the Hot Lab. They can be used if Gamma Radiation is being used. 4.7 SAFETY SHOWERS AND EYEWASHES An integral unit consisting of both safety shower and eyewash is situated at the main door of the laboratory. 4.8 FORMS - Daily When working with Radiation a number of forms must be completed on each occasion of use. These include: Log sheet Record the date, time and isotope, together with the results of monitoring the Work Bay and Equipment used both before and after usage. (Found on the main door of the Hot Lab) Isotope Usage Logbook Record the date, the quantity of isotope removed from the Stock Isotope container, and the quantity remaining, and your name. (Found in the 2 nd Drawer under the Ordering Bench in LS3-26) Waste Disposal sheets Record the amount of isotope disposed of as Liquid and/or Solid waste, choosing the appropriate sheet for the specific isotope used and recording the quantity of isotope in either

4 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 4 of 12 Curie or Becquerel. (Found in the top drawer of the Documentation set of drawers) 4.9 FORMS weekly Hotlab Cleanup Record the monitoring of all areas of the Radiation Laboratory, the state of order and the restocking of the Laboratory. Refer to GDP 023 HotLab Cleanup Waste Disposal to Bunker Measure the quantity of Solid and Liquid Waste to be disposed of. Calculate the Decay date of each container / bag of waste. Record the radioisotope, the quantity in Becquerel and the date of decay to less than 100Bq per gram, in the Waste Disposal Book. (Found in the top drawer of the Documentation set of drawers) Record the same information on a Waste Disposal Card which is to be attached to the container / bag. Record the same information in the Radiation Waste Record Book inside the door of the Bunker. Refer to GDP 024 HotLab Waste Disposal ISOTOPE USAGE LOGBOOKS Accessioning Isotopes All isotopes arriving in the laboratory must be accessioned. Details of the type of isotope, quantity of radioactivity, volume, manufacture date or activity date and chemical form should be recorded. Refer to GDP 022 Accessioning Radioactive Isotopes into the Laboratory SHIELDING Perspex Shielding - is provided for use with Beta-emitters. The shielding of thickness 1cm should be placed between the radioactive source and personnel when using Beta-emitting isotopes such as 32 P Perspex workstations are provided and can be used as a secondary containment units in the workbays Perspex sample holders are also provided for transportation or storage of radioactive beta-emitters Lead Shielding - is available in either lead blocks or sheets of lead. The lead shielding should be placed between the radioactive source and personnel when using Gamma-emitting isotopes such as 125 I. NOTE lead shielding is not suitable for use with beta-emitting isotopes as it results in the secondary emission of X-rays, known as Bremsstrahlung

5 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 5 of 12 radiation Lead apron the lead apron acts as a shield from gamma radiation SECONDARY CONTAINMENT All procedures involving radioactive isotopes must be isolated by means of secondary containment. The perspex workstations may act as a secondary containment for work involving 32 P. When working with other isotopes such as Tritium, all work must be conducted in a tray so that any spills will be contained PERSONAL MONITORS All personnel working in the Radiation Laboratory or who may potentially become exposed to radiation must be issued with a TLD (Thermoluminiscent Detector). This TLD must be worn all the time when at work. Since TLD badges are a record of occupational exposure, they should not be taken home. It is an offence for anyone other than the person specified, to use the TLD, or for TLDs to be swapped between personnel. The TLD badge is changed every 12 weeks and sent away for analysis. In exceptional circumstances the Radiation Safety Officer can organise for an immediate readout. The School Safety Officer takes charge of the TLDs. They arrange their provision to appropriate personnel and the 3-monthly collection and analysis of exposure. The School Safety Officer can be contacted on 16819to arrange provision of the TLD or this can be arranged by the Radiation Safety Officer HANDLING OF THE TLD BADGES. The radiation TLD badge is used to measure the amount and type of radiation received by the wearer over a period of time (typically 3 months). It plays an important part in radiation safety, providing a check of the adequacy of protection measures, and in the case of a radiation accident an assessment of the dosage received by the wearer. Failure to observe these rules can result in misleading assessment of radiation exposures. TLDs are not recommended for persons exposed only to Tritium radiation, as the Tritium energy is so low that it would not even penetrate the paper of the TLD. Precautions to be taken:

6 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 6 of Always use the TLD sachet inside the holder supplied. The holder incorporates filters which allow an assessment of the radiation quality. 2. Wear the holder correctly. The ARPANSA symbol should face away from the body. 3. Do not damage the badge. Pin holes, water, pressure, chemicals and heat can damage the TLD badge and prevent evaluation of the dose. 4. Do not store TLD badges near radiation sources when not being worn. 5. Return the TLD badges promptly. Badges must be returned to ARL upon receipt of a new batch. Extended delay increases the chances of accidental exposure of the badge. Also, in case of a dose recorded by the badge it is important to evaluate it as soon as possible so action can be taken to prevent exposure in the future. If it is suspected that a person has received a significant radiation dose, please return the TLD badge for assessment immediately! 6. Always wear the TLD badge under a lead apron, if used. Since the badge is used to measure radiation exposure to the body, it should not be worn outside of protective clothing. Similarly, care should be taken not to shield the badge by pens, buckles, etc. SIGNIFICANCE OF THE TLD RESULTS The permitted levels of radiation allowed for occupationally exposed workers and members of the general public have been laid down by the ICRP (report 60, 1991) as amended in the National standard for limiting exposure to ionizing radiation ( National Occupational Health and Safety Commission publication 1013(1995). They are incorporated in the NSW Radiation Control Act Regulation(2003). The permitted levels are as follows: Occupationally exposed persons o Effective dose limit 20 m Sv per annum Averaged over a period of 5 consecutive calendar years. o Effective dose limit in a single year 50 msv. o Equivalent dose limit In the lens of the eye 150 msv. per year In the skin 500 msv. per year In the hands and feet 500 msv. per year Others, including members of the general public 1 m Sv per annum ( When an employee declares that she is pregnant, the embryo or foetus should be afforded the same level of protection as required for members of the public) In general, TLD badges provide a measure of the whole body dose received. For practical purposes the allowable limit can be taken to be 0.5 msv per week, for radiation workers. However, it is recommended that any radiation dose received by any person should be kept to the minimum value practical. The School/building or University Radiation Safety Officer is available to assist in the minimisation of radiation exposure to personnel. (Copied from the University Radiation Safety Manual) 4.14 EMERGENCY PROCEDURES A copy of the laboratory s Emergency Procedures is posted on the wall in the Hot Lab above the freezer. Ensure that you are familiar with these procedures and have the knowledge to act immediately in the case of a radioactive spill.

7 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 7 of CHEMICAL SPILL KIT / PERSONAL SPILL KIT A chemical spill kit is available in the laboratory and is situated on top of the Fridge. In addition there is a personal spill kit which contains such chemicals as identified in the Emergency Procedures as required for personal decontamination ORDERING RADIOISOTOPES - UNIVERSITY LICENCE TO POSSESS When ordering radioisotopes the supplier should ask you for the Licence number under which the order is being placed. The appropriate licence number to quote in this instance, is the University's Licence to possess: 5. Shutdown: 5.1 Once all compulsory General Discipline Procedures have been read, complete the record sheet (Illustration 6.1) and give it to your supervisor for filing in the Personnel Training File. 5.2 Fill in and sign the record sheet (Illustration 6.2) to indicate any other Procedures that you were requested to read. Once complete, give this to your supervisor for filing in the Personnel Training File. 5.3 Visit the Radiation Laboratory with the Radiation Safety Officer and fill in the Radiation Laboratory Induction Checklist (Attachment 7.1) 5.4 This GDP must be reviewed and reissued at least every five years, or updated and reissued as required. 5.5 All records must be retained for 50 years. 6. Illustrations: (see attached) 6.1 Compulsory Reading Record Sheet 6.2 Requested Reading Record Sheet 7. Attachments 7.1 Radiation Laboratory Induction Checklist 7.2 Exemption Form for Radiation Laboratory 8. Change History: 8.1 Issue Number: 1st Issue Date Issued: 29 th April 2003

8 SCHOOL of BIOMEDICAL SCIENCES RADIATION LABORATORY PROCEDURE NO: BS-GDP 021 Page: 8 of Issue Number: 2nd Issue Date Issued: 16th June 2004 Reason for Change: Defining requirements for wearing of TLD's and retaining all records for 50 years. 8.3 Issue Number: 3rd Issue Date Issued: Reason for Change: Addition of laboratory registration, removal of Faculty Support Services, addition of information re tritium and TLD's, change to University website.

9 THE UNIVERSITY OF NEWCASTLE- DISCIPLINE OF MEDICAL BIOCHEMISTRY STANDARD OPERATING PROCEDURE PROCEDURE NO: GDP 021 MOD: 3rd Issue Page: 9 of 12 Procedure Type: General Department Procedure ILLUSTRATION 6.1 COMPULSORY READING RECORD SHEET NAME: START DATE: POSITION: SUPERVISING STAFF MEMBER: RADIATION SAFETY OFFICER: COMPULSORY READING: RECEIVED AND UNDERSTOOD: BS-GDP 001 Induction Procedure Signed: Date: BS-GDP 002 Training Procedure Signed: Date: MHS 003 Evacuation Procedure (Life Sciences/Medical Signed: Date: Sciences) BS-GDP 005 General Laboratory Safety Signed: Date: BS-GDP 008 Radiation Safety Signed: Date: BS-GDP 021 Signed: Date: BS-GDP 022 Accessioning Radioactive Isotopes Signed: Date: BS-GDP 018 Radiation Laboratory Routine Procedures Signed: Date: BS-GDP 023 Radiation Laboratory Cleanup Signed: Date: BS-GDP 024 Radiation Laboratory Waste Disposal Signed: Date: BS-GDP 028 Wipe Test Method for Detecting Radioactive Signed: Date: Contamination

10 THE UNIVERSITY OF NEWCASTLE- DISCIPLINE OF MEDICAL BIOCHEMISTRY STANDARD OPERATING PROCEDURE PROCEDURE NO: GDP 021 MOD: 3rd Issue Page: 10 of 12 Procedure Type: General Discipline Procedure ILLUSTRATION 6.2 REQUESTED READING RECORD SHEET NAME: START DATE: POSITION: SUPERVISING STAFF MEMBER: RADIATION SAFETY OFFICER: REQUESTED READING READ AND UNDERSTOOD: BS-GDP 006 Chemical Safety Signed: Date: GDP 011 Spill Procedure Signed: Date: BS-GDP 017 Procedure for Weekly Lab Cleanup Signed: Date: GEP 060 Victoreen Radiation Monitor Signed: Date: Signed: Date: Signed: Date:

11 School of Biomedical Sciences Medical Biochemistry Radiation Laboratory RADIATION LABORATORY INDUCTION This form is designed to induct new personal or students into the safety practices used in this laboratory. This form can also be used to induct staff or students who have been using the laboratory for some time. Inductees can be asked if they have received this information and confirm that they have understood it by way of questioning or demonstration. This record will then be signed after reading and checked by the laboratory manager and kept as a record of induction. Laboratory: LS3-18 Lab Manager: Lynn Herd Radiation Safety Officer: Lynn Herd Name: Signature: Date: Inducted by: Supervisor Acknowledgement: INDUCTION ITEM or PROCEDURE Induction into Medical Biochemistry (as required) Completion of University Radiation Safety Course Review contents of Radiation Safety Procedure (GDP 008) Understanding of Duty of Care Evacuation Procedures Location of Staff Training Folder Laboratory access requirements Location of fire fighting equipment Location of First Aid Kit Location and use of chemical spill kits Location and use of Radiation Spills Kit Location of Emergency Procedures booklets Location and Use of Safety Showers and Eyewashes Location of Safety Documentation: Laboratory General Discipline Procedures Laboratory General Equipment Procedures Laboratory General Laboratory Procedures Material Safety Data Sheets / Chemical Lists Equipment Folder CHECK

12 School of Biomedical Sciences Medical Biochemistry Radiation Laboratory RADIATION LABORATORY INDUCTION Issue of Personal Protective Equipment: Safety Glasses Lab coat or gowns Personal Radiation Exposure Monitor (TLD) Appropriate footwear in the laboratory Location of other Personal Protective Equipment: Shielding Gloves Waste Disposal Procedures Daily including Separation of isotopes; separation of liquid / solid waste and record of waste Weekly including calculation of Decay date; and documentation of waste to bunker Daily records of use of Hotlab Hotlab monitoring for radioactivity: As part of daily work procedure Weekly roster for monitoring laboratory Use of Radiation Monitor (Victoreen) Use of Fridges / Freezers and recording of contents Radioisotopes: Location Accessioning into lab Record of use Ordering (use of University Licence Number) Location of Radiation Safety Documentation: Radioisotope Accessioning and Record of Usage Manuals Daily Laboratory Usage sheets Waste Disposal forms Waste Disposal Record books LS3-18 and Bunker Hotlab Radiation Monitoring Record sheets Emergency Procedures Security: Locking of laboratory / offices Emergency phone number Application for a Radiation Licence or Student Exemption

13 SCHOOL OF BIOMEDICAL SCIENCES THE UNIVERSITY OF NEWCASTLE Post Graduate Student Radiation Licence Exemption Form Name of Supervisor and Licence Holder: Licence No: Home Address: Phone: After Hours: Name of Post Graduate Student: (requiring general supervision) Home Address Phone: After Hours: Course: Radiation substances to be used: Type of Procedures: Special Circumstances: Note: "General Supervision" means supervision by a qualified supervisor who oversees the person being supervised and ensures that the person follow safe radiation work practices in relation to the use of radioactive substance or radiation apparatus. I have read the University of Newcastle's Radiation Safety Manual and agree to comply with them and any other requirements of my supervision. Student's Signature: Date: I agree to provide general supervision to... in the handling of radioactive material. I am aware of the requirements of the Radiation Control Act of NSW and its Regulation (1993) and agree to comply with them. Supervisor's Signature: Date: Please Note: One copy of this form must be retained by the student, one by the Supervisor, one to the Building Radiation Safety Officer and one displayed near where the student is carrying out the above procedures.

14 2.9.2 Exemptions There are exemptions to the requirement for licenses and these apply mainly to students and are as follows: 1. a person who is a student in medical radiation technology and is a trainee technologist in nuclear medicine, diagnostic radiology and radiation oncology; 2. an undergraduate student in a university or other educational institution who is undertaking course work or research; 3. a postgraduate student in a university or other educational institution who is undertaking research or higher studies. These exemptions must be confirmed by the Supervisor/Licence Holder and must be in writing specifying the radioactive substance(s) or irradiating apparatus and set out any specific conditions and must identify the person and their supervisor. (See Appendix 6) The Supervisor then has specific responsibilities: (i) A person referred to in 1. and 2. above must have immediate supervision while the person is using radioactive substances or radiation apparatus during clinical experience and general supervision at all other times by a qualified person. (ii) A person referred to in 3. above (ie a postgraduate student) must have general supervision at all times by a qualified person. Clearly, the simplest way to cover the situation (although perhaps not the most economical) would be to train up the postgrads and purchase full licenses for them Licences for Teaching and/or Demonstration Purposes Members of staff who are involved in the teaching of both postgraduate students with exemptions or undergraduate students in the safe use and disposal of unsealed radioisotopes (where each student uses substantial quantities) the use of x-ray analysis equipment and therapeutic x-ray equipment are required to be specially licensed. Again these licenses (category Iq and Rq) are available from the Radiation Control Branch of the EPA Supervision "general supervision" which means supervision by a qualified supervisor who oversees the person being supervised and ensures that the person follows safe radiation work practices in relation to the use of radioactive substances or radiation apparatus; "immediate supervision" means supervision by a qualified supervisor who is present at all times during, and is observing and directing, the use by the person being supervised of radioactive substances or radiation apparatus; "qualified person", in relation to supervision for a particular radioactive substance or item or radiation apparatus, means a person who is the holder of a licence which allows the person to provide supervision with respect to that substance or item.

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