RADIATION SAFETY MANUAL

Transcription

1 RADIATION SAFETY MANUAL AUGUST 2016

2 TABLE OF CONTENTS Foreword... 1 Introduction Organizational Chart Radiation Safety Committee... 3 a) General Description... 3 b) Duties and Functions... 3 c) Responsibility of Chairman Radiation Safety Officer... 5 a) General... 5 b) Responsibilities... 5 c) Additional Functions... 6 d) Authority Definition of Users of Radioactive Materials and Radiation Producing Machines... 7 a) General... 7 b) Authorized User... 7 c) Qualified User... 7 d) Restricted User... 8 e) Direct or Personal Supervision Application Procedures and General Criteria for Approval... 9 a) General... 9 b) Application Submission... 9 c) Approval Criteria... 9 d) Authorization... 9 e) Renewal or Amending the Authorization Individual Responsibility a) All Users b) Authorized Users Radiation Protection Procedures a) Authorized User b) Rules and Procedures for Laboratory Personnel c) General Rules and Procedures d) Contamination Control e) Personnel Monitoring and Area Monitoring f) Use of Protective Equipment g) Special Procedures ii

3 8. Radiation Monitoring And Control a) Surveys b) Periodic Survey Frequency c) Exemption from Survey d) Removable Surface Contamination Action Levels e) Exposure Rate Limits f) Survey Instruments Instrument Calibration a) General b) Calibration c) Pulser Calibration d) Reference Check Source Radiation Dose Limits a) General b) Adults c) Minors d) Dose to Embryo/Fetus e) Individual Members of the Public f) Internal Dose g) As Low as Reasonably Achievable Guidelines Posting and Labeling a) Posting Signs b) Exceptions to Posting Signs c) Labeling Containers d) Restricted Area Personnel Monitoring and Bioassay Procedures a) General b) External Monitoring c) Bioassays Radioactive Waste Disposal Procedures a) General b) Preparing Radioactive Waste for Disposal c) Records Animal Use Procedures a) Animals and Radioactive Materials: Rules and Procedures for Authorized Users b) Containment c) Waste Disposal d) Animals and Radioactive Materials: Rules and Procedures for Animal Caretakers iii

4 15. Inventory Control for Radioactive Materials a) General b) Ordering c) Receipt d) Disposal e) Inventory f) Termination Inventory Purchasing Radioactive Material a) Purchasing Procedures b) Receiving Procedures c) Package Opening and Monitoring Transfer and Transport of Radioactive Material a) General b) Transport Human Use of Radioactive Materials Radiation Producing Machines - Responsibilities a) Supervisor b) Operator Policies and Procedures for Radiation Producing Machines and Areas a) General b) Policies c) Procedures Appendix A - Emergency Procedures... 1 a) General Principles... 1 b) Minor Spill Involving No Radiation Hazard to Personnel... 1 c) Major Spill... 2 d) Minor Fire... 2 e) Major Incident Involving Fire, Explosion, or Other Major Event... 3 f) Accidents Involving Airborne Radioactivity... 3 g) Injuries to Personnel Involving Contamination... 4 h) Decontamination of Personnel... 4 i) Loss or Theft of Radioactive Materials... 6 j) Supplement to Radiation Emergency Procedures for Police and Public Safety Officers... 6 k) Incident Reporting to Press and Public... 7 l) Supplement to Emergency Procedures for Radiation Safety Personnel... 7 Appendix B - Radiation Protection Terms... 1 Appendix C - Procedures for Identifying and Reporting Defects... 1 Appendix D - Forms... 1 iv

5 FOREWORD The Radiation Safety Manual represents one part of a commitment by the administration of the Eastern Virginia Medical School (EVMS) to keep occupational radiation exposures as low as reasonably achievable (ALARA). While radiation exposure to patients in the healing arts has demonstrated a large benefit-to-risk ratio for both diagnosis and therapy, there is widespread agreement among physicians, scientists, and regulatory agencies that occupational exposures should be minimized as far as is practical. EVMS has created, staffed, and equipped a Radiation Safety Office, within the Department of Environmental Health and Safety, to oversee the use of radioactive material in research. EVMS is committed to adequately training investigators using radioactive material and to supporting the staff of the Radiation Safety Office in their efforts to assure compliance with regulations and to keep radiation exposures ALARA. The administration welcomes input from radiation workers about our radiation safety program. Modifications to operating and maintenance procedures, and to equipment and facilities, will be considered where they will substantially reduce radiation exposures at reasonable cost. INTRODUCTION With the use of radioactive materials and radiation producing machines, it is imperative that these materials be used in a manner to minimize radiation exposure to personnel and the environment. EVMS operates within regulations issued by the Commonwealth of Virginia (Radiation Protection Regulations, Chapter 481 of the Virginia Administrative Code). These regulations constitute minimum requirements for maintaining a safe and productive workplace. The general policy of the Eastern Virginia Medical School is to keep radiation exposure ALARA. Strict adherence to this manual will help ensure safety to those using radioactive material or radiation producing machines. Failure to employ safe practices and procedures could result in excessive personnel or environmental exposure and may jeopardize the institutional licenses. The EVMS Radiation Safety Committee (RSC) issues this Radiation Safety Manual. All personnel using radiation sources are expected to be familiar with the requirements of it and to conduct their operations within its framework. Comments or recommendations concerning the contents should be submitted to the Radiation Safety Office. 1

6 1. ORGANIZATIONAL CHART The administrative structure to supervise the possession of radiation sources and their use within EVMS is shown below. For details concerning these relationships, see sections, 2, 3, 4 and 6. 2

7 2. RADIATION SAFETY COMMITTEE a) General Description The RSC shall be a standing committee of EVMS. The RSC shall be appointed by the Dean, and consist of at least the Senior Associate Dean for Research, the Radiation Safety Officer (RSO), two or more faculty members engaged in work with radioactive material and one fulltime laboratory technician who is involved in the routine use of radioactive materials. The Senior Associate Dean for Research, the RSO and the technician will not be eligible to serve as permanent Chairman of the Committee. The RSC shall meet at least quarterly and upon call of the Chairman. A quorum shall consist of four members, three of whom must be the Chairman or Vice Chairman, the Radiation Safety Officer or Associate Radiation Safety Officer and the Administrative Representative or alternate. Application to use radioactive material is made on forms to the RSC. The Chairman, the RSO and at least two other RSC members review the applications. Criteria are established for approving new users and uses of radioactive material. The RSC has the sole responsibility for the possession and use of radioactive materials and sources of radiation. The RSC is the final authority within EVMS in all matters pertaining to the establishment and administration of the Radiation Safety program. This Committee has been designated by the Virginia Department of Health, Division of Radiological Health, as the responsible agent for EVMS. Curricula vitae for RSC members shall be kept on file in the Radiation Safety Office. b) Duties and Functions The duties and functions of the RSC are to: i. Establish rules, regulations, policies and overall guidance regarding EVMS radiation safety and radiation producing machines. ii. Review and act upon all applications for possession and use of radionuclides or radiation producing machines. iii. Establish procedures to ensure adequate personnel and environmental protection for persons working with radioactive material and radiation producing machines. iv. Review and approve program procedural changes prior to implementation. v. Annually review the Radiation Safety program, activities of the RSO, and records that must be maintained to ensure compliance with conditions of licenses with the Commonwealth of Virginia and federal and state regulations. vi. Receive and review periodic reports from the Radiation Safety Officer. vii. Review instances of non-compliance with procedures for use of radioactive materials or safety rules established by the Radiation Safety Office. The review will include analysis of the cause, corrective actions and actions to prevent recurrence. viii. Report annually to the EVMS President, Provost and Dean. 3

8 c) Responsibility of Chairman It shall be the responsibility of the Chairman to: i. Report periodically the actions of the RSC to the Dean or his/her designate. ii. Call for meetings of the RSC. iii. Circulate minutes of the RSC meetings to other committees with responsibility in the area of biosafety or hazardous chemicals, and to establish coordination with other responsible committees, such as the Institutional Review Board (IRB), Institutional Biosafety Committee (IBC), and Institutional Animal Care and Use Committee (IACUC). iv. Appoint subcommittees to deal with specific areas of radiation as needed. v. Vote in Committee matters. vi. Inform RSC members of their duties, functions, and responsibilities. 4

9 3. RADIATION SAFETY OFFICER a) General The Radiation Safety Officer (RSO) is appointed by the authority of the President, Provost and Dean, EVMS, and who by reason of education, training, and experience, is qualified to advise others in the safe use of radiation. He/she shall be a member of the administration and a member of the Radiation Safety Committee. The primary mission of the RSO is to execute the policies established by the RSC and to ensure compliance with Federal and State regulations. It is the policy of the Radiation Safety Committee that the Radiation Safety Officer and other Radiation Safety personnel to provide radiation protection service to the EVMS community. This service extends from health and safety functions through legal and administration duties, to the procurement, use and disposal of radioactive materials and other sources of radiation. A Radiation Safety Office is established to provide these services. The Radiation Safety Officer reports to the Senior Associate Dean of Research for administrative purposes and to the Radiation Safety Committee for matters pertaining to institutional radiation safety. b) Responsibilities The Radiation Safety Officer is responsible for: i. Monitoring and surveys of all areas in which radioactive material is used. ii. Oversight of ordering, receipt, surveys, and delivery of byproduct material. Monitoring and maintaining systems associated with the use, storage, or disposal of radioactive material. iii. Packaging, labeling, surveys, etc., of all shipments of radioactive material leaving the licensed facilities. iv. Personnel monitoring program, including determining the need for and evaluating bioassays, monitoring personnel exposure records and developing corrective actions for exposures approaching maximum permissible limits. v. Training authorized, qualified and restricted users and ancillary personnel. vi. Radioactive waste disposal program. vii. Inventory and leak tests of sealed sources. viii. Decontamination ix. Investigating any incidents and responding to any emergencies involving radioactive material. x. Maintaining all required records. 5

10 c) Additional Functions The Radiation Safety Officer will provide a: i. Semi-annual report of inventory of radioactive materials at EVMS. ii. Report at every quarterly meeting of the RSC of unusual or abnormal incidents involving radiation and radioactive material. d) Authority The Radiation Safety Officer has the authority to immediately terminate a project, activity or use of radiation or radioactive material that is found to be a threat to health or property. This would include closing a laboratory or confiscation of radioactive material, if such actions would remove or prevent the recurrence of a threat to health or property. Any such action by the RSO must be reported in writing to the Chairman of the RSC within 48 hours. 6

11 4. DEFINITION OF USERS OF RADIOACTIVE MATERIALS AND RADIATION PRODUCING MACHINES a) General The Radiation Safety Committee (RSC) is empowered to authorize the possession and use of radioactive materials and radiation producing machines. Several categories of users have been established for which an individual may apply. These are "Authorized User", "Qualified User" and "Restricted User." A discussion of each category including the particular responsibilities and authorizations follows. A chain of responsibility regarding the safe use of radioactive material and radiation producing machines exists from individual users to the RSC. This chain is independent of other administrative lines of control within EVMS. However, the RSC recognizes the right of any administrative entity within EVMS to impose additional restrictions, qualifications, and regulations regarding the use of radioactive material, radiation or equipment by persons under its control. Responsibilities of radionuclide users are outlined in Section 6, and the procedures an individual must follow to become a user are presented in Section 5 of this manual. b) Authorized User A person designated by the RSC as an "Authorized User" may possess and use radioactive materials and/or radiation-producing machines as specified in their permit from the RSC. An Authorized User is responsible for proper storage of materials under his/her control and for their proper use under his/her direction. An Authorized User may initiate purchase or transfer of radioactive materials, as described in this manual. In general, Authorized Users should be permanent members of EVMS with significant training and experience in the use of radioactive material and would have a position that allows them to administer the use of radioactive materials under their authorization. An Authorized User may sponsor the use of radioactive materials and radiation producing machines by Qualified Users and personally supervise Restricted Users. c) Qualified User The category of "Qualified User" is established to allow individuals to use radioactive material or radiation producing machines in specific circumstances under the sponsorship of an Authorized User. The Authorized User shall bear primary responsibility for training the Qualified User in laboratory procedures using radioactivity and for the safe use and storage of the material. The Qualified User category is intended for students or technical employees with adequate training and experience in the use of radioactive material whose association with EVMS may not be permanent and whose background may not be extensive enough to warrant a broad authorization to use radioactive materials or radiation producing machines. The Qualified User works under supervision of an Authorized User and may independently use radioactive material in protocols approved in the Authorized Users permit. 7

12 d) Restricted User A "Restricted User" is one who has not received authorization by the RSC as either an Authorized or Qualified User. Generally, a Restricted User has had prior training and experience working with radioactivity but hasn t completed radiation safety training at EVMS. A Restricted User may only use radioactive materials or radiation producing machines under direct supervision of an Authorized User. Authorized Users are required to notify the RSO in writing when an individual is working for them as a Restricted User. The memo should include the Restricted User's name and date they became a Restricted User. e) Direct or Personal Supervision i. Direct supervision requires that the operation be planned by the Authorized User, the Restricted User has been told of potential hazards and been instructed in procedures to be followed both in normal circumstances and in the event of an abnormal occurrence or accident. ii. When the operation involves unsealed sources of radioactive material, the Authorized User must remain in the room while the radionuclide is in use. iii. When the operation involves sealed source or sources which do not present dose rates at the accessible boundary of the restricted area exceeding 2.0 mrem/hr, the Authorized User need not remain in the room. However the Authorized User must be in the same general area of the building where the radionuclide is in use, and must be aware of the operation in progress. 8

13 5. APPLICATION PROCEDURES AND GENERAL CRITERIA FOR APPROVAL a) General Application for possession and use of sources of radiation, and for Authorized User or Qualified User Status, will be made using the appropriate hard copy or electronic forms available from the Radiation Safety Office. The application procedure is in two parts. The first parts is "Training and Experience" (RSO- 1 Application for User Status ) while the second part is "Possession and Use" (RSO-2 Application for Possession and Use and/or RSO-4 Application for Radiation Device ). "Possession and Use" applications must be renewed every two years, while a "Training and Experience" application is only needed initially or when significant changes occur. b) Application Submission Applications will be submitted to the RSO for preliminary review. The RSC Chairman, the Radiation Safety Officer and at least two other members of the RSC will then review the application. Between regularly scheduled meetings, review and approval will ordinarily be done by and telephone. c) Approval Criteria Applications may be approved if the RSC is satisfied that the applicant: i. Has adequate training and experience to safely conduct the proposed use. ii. Possesses adequate facilities and equipment (including shielding, containment, and survey instruments) appropriate for the proposed use. iii. Has safe and effective operating, handling, survey, security, accountability and emergency procedures. iv. Conforms to all applicable procedures and regulations regarding safe use of radionuclides. d) Authorization When approved by the Radiation Safety Committee, a copy of the application will be appropriately marked and returned to the applicant to serve as his/her permit. e) Renewal or Amending the Authorization Permit renewal is accomplished by submitting an RSO-3 AU Renewal Application to the RSC. To amend the permit on the RSO-3, submit page 1 with "Amendment" marked, page 5 with signature and other pages containing modifications. If the amendment is for possession quantity only, a memo may be submitted indicating the desired change. 9

14 6. INDIVIDUAL RESPONSIBILITY a) All Users Each individual at the Eastern Virginia Medical School, regardless of category or authorization, who has contact with radioactive materials or other radiation sources is responsible to: i. Be familiar with the EVMS Radiation Safety Manual. ii. Keep his/her exposure to radiation and that of those working under his/her supervision As Low As Reasonably Achievable (ALARA), and specifically below the maximum permissible doses listed in 12VAC5-481 and Section 10 of this manual. Concentrations of radioactive materials in laboratory air shall be maintained below levels specified in 12VAC iii. Wear prescribed radiation dosimeters in radiation areas. Personnel who work only with alpha emitters or beta emitters having a maximum energy of less than 200 kev will not be required to wear radiation dosimeters. iv. Conduct precautionary personnel surveys at frequent intervals with a suitable survey instrument, according to their approved permit and maintain required records. v. Limit the use of their authorized radionuclides to individuals working under their direct supervision and to the location specified in their permit. vi. Keep current working records of the receipt and disposal of radionuclides in their possession, (e.g. research, waste disposal, transfer, storage, records, etc.). The Radiation Safety Office may audit these records at any time. vii. Transfer radioactive materials in accordance with this manual and all applicable regulations. viii. Assure that smoking, eating, drinking, and the application of cosmetics are prohibited in areas in which unsealed radioactive materials are present. b) Authorized Users In addition to items listed above, Authorized Users are further responsible for: i. Adequate planning. Before an experiment is performed, the User should determine the types and amounts of radiation or radioactive material to be used. This will generally dictate the level of protection required. Procedures must be well outlined. In most cases, before the procedure is actually performed with radioactive materials, it should be rehearsed to preclude accidents or unexpected circumstances. ii. Being readily available when radionuclides in their permit are being used. iii. Instructing Qualified and Restricted Users to use safe techniques and apply approved radiation safety practices. iv. Furnishing the Radiation Safety Officer with information concerning individuals and activities in their areas, particularly additions to or deletions from their personnel rosters. v. Contacting the RSO whenever changes in operational procedures may lead to potential personnel exposure. 10

15 vi. Complying with the regulations governing the use of radioactive materials established by the Nuclear Regulatory Commission, Commonwealth of Virginia and the EVMS Radiation Safety Committee for: Following the correct procedure for procurement of radioactive materials by purchase or transfer. Posting indicators of radiation areas and areas where radioactive materials are used or stored. Accounting for the disposition of radioactive materials in their possession. Inventories of nuclides must be completed and received by the RSO every six months. Assuring that all radioactive waste materials are consigned to the Radiation Safety Office for disposal. Reporting any incident or unusual occurrence related to the radioactive material or radiation producing equipment in their possession. Informing the Radiation Safety Committee prior to any minors (persons under 18) engaging in activities involving radiation and radioactivity. Informing the Radiation Safety Officer prior to any declared pregnant woman who may be occupationally exposed to ionizing radiation. 11

16 7. RADIATION PROTECTION PROCEDURES The purpose of this section is to provide a safe working environment for laboratory personnel, to ensure public safety and to avoid contamination of equipment and facilities. a) Authorized User i. Discuss with employees the work to be done and the necessary safety precautions. ii. Outline in writing the procedure for each job (make the amount of detail commensurate with the potential hazards). iii. Stock the laboratory with plastic or rubber gloves, lab coats, warning tags and labels, wipes, appropriate survey/counting instruments, forms for necessary records, plastic bags and tape for waste disposal, absorbent paper, etc. The use of good procedures is greatly enhanced by having proper tools/supplies available. iv. Make arrangements with the Radiation Safety Office for radioactive waste disposal. v. Have available and appropriately use remote handling devices, automatic pipettes or dispensers, tongs, etc., for the manipulation and transfer of radioactive preparations. b) Rules and Procedures for Laboratory Personnel Radioactive material may only be handled by individuals authorized by the Radiation Safety Committee according to their approved permit in designated areas. Radiation Safety Office staff may handle radioactive materials using accepted health physics practices and procedures. c) General Rules and Procedures The following rules and procedures apply to all use of radioactive material are: i. Wear a lab coat or other protective clothing at all times when working with radioactive materials. Remove and secure the lab coat within the lab before leaving the lab. ii. Wear non-powdered disposable gloves when handling radioactive material. Change gloves frequently to prevent the spread of contamination. iii. Remove gloves at the work area. Do not touch faucets, light switches, computer keyboards, telephones, doorknobs or other common use items with contaminated or potentially contaminated gloves. iv. Monitor hands, feet and clothing in a low background area after procedures or before leaving the lab. v. Do not eat, drink, smoke or apply cosmetics in any area where radioactive material is used or stored. vi. Use mechanical pipetting devices. DO NOT PIPETTE BY MOUTH! d) Contamination Control i. Designate an area in the lab to conduct work with radionuclides. Place plastic backed absorbent material on the work area and place radiation tape on the boundary of the absorbent material. Monitor the work area and dispose of contaminated materials. ii. Mark equipment and lab ware used for work with radioactivity with radiation tape to indicate it may contain contamination. 12

17 iii. Designate a sink for cleaning contaminated glassware. Notify Radiation Safety so a tag can be placed on the sink trap to alert Maintenance to the need for monitoring and protective procedures prior to and during repair work. iv. Place radioactive material labels on storage areas such as refrigerators, freezers or storage areas. Ensure that container with radioactive material are clearly marked with a radiation labels that identifies the radionuclide, quantity and date. v. Perform surveys in accordance with requirements of their approved protocols and the procedures in the Surveys section. e) Personnel Monitoring and Area Monitoring i. If issued radiation monitoring device(s), wear it at all times when in radioactive materials storage or use areas. If the dosimeter is lost, immediately notify Radiation Safety. ii. Do not handle dosimetry (personnel or area) with potentially contaminated gloves f) Use of Protective Equipment i. When using unsealed beta emitting radionuclides with energies greater than 250 kev, place an acrylic, or equivalent, shield between the user and the source. The shield should be at least ¼ inch thick. Additional shielding may also be necessary behind the source to prevent exposure to coworkers on the other side of the bench. ii. Use protective eyewear when pipetting liquids containing radioactivity. iii. Respirators used for protection from airborne radioactivity must be approved in advance by Environmental Health & Safety in consultation with the RSO. g) Special Procedures i. Iodination Iodinations that use an oxidative process (such as the iodine monochloride, lactoperoxidase, and chloramine-t processes) risk releasing radioactive iodine gas to the atmosphere. In order to protect personnel and the environment, oxidative iodinations are to be done according to the following procedures, in addition to the General Procedures listed above. The iodination and all steps involving the potential release of radioactive iodine gas must be performed in an operating radiochemical fume hood with a volume flow rate of at least 15,000 liters per minute (430 CFM) and a face velocity of at least 40 meters per minute (130 FPM). Filters to trap the radioactive iodine gas should be employed. The fume hood must not be shut off for at least 24 hours after the last iodination. Iodination All iodinations will be performed in the EH&S fume hood. Contact EH&S at least 21 days in advance to schedule the activity. EH&S will perform a baseline thyroid assay of the User, monitor for contamination during the procedure. A follow-up thyroid assay will be performed hours after the iodination and again days later. 13

18 iii. Authorized Users and other radiation workers will cooperate with Radiation Safety staff in performing breathing zone and environmental air sampling as deemed necessary by the RSO. Radiation workers involved in the iodination and preliminary purification steps will have thyroid counts performed before, and hours and days after each iodination procedure; or every two weeks, during repeated iodinations. The ph of liquid radioactive wastes from iodination procedures must be alkynized, to reduce the off gassing of radioactive iodine. ii. Recommendations for the Use of Tritium-Labeled Sodium Borohydride Sodium borohydride (NaBH 4 ) labeled with tritium is a useful reagent for reducing certain organic compounds and labeling them with tritium. It is very hygroscopic and hydrolyzes readily (even with humidity in the air) to release tritium gas. It is not stable in any solutions in which hydrogen ions are present, although the useful life in solution can be extended by alkalinizing the solution. Increase ph of Iodination Waste Addition of a base Raise to ph 9 or above Reduces gas release by driving the reaction to the left: 4I H + ß 2I 2 (gas) + 2H 2 0 Tritium-Labeled Sodium Borohydride Procedure Use the following procedure when using tritiated NaBH4: Perform all work with the crystalline stock material or solutions in an operating hood. This includes initial unpacking, as all vials of stock material are found to contain high concentrations of radioactive gas, and weighing out of stock. When hood operations are not possible, such as during centrifugation or shaking operations, cover containers tightly with caps or two layers of paraffin film. Monitor all areas where NaBH 4 ( 3 H) has been used for removable contamination by doing wipe tests and counting them in a liquid scintillation counter. Do Not mouth pipette radioactive solutions. Use disposable waterproof gloves in all radioactive operations, and cover work areas with plastic-backed absorbent material. Change gloves frequently. All liquid waste should be acidified and stored in a hood for at least 24 hours, and boiled if possible. The acidification will degrade the BH 4 ions and the boiling will remove any dissolved tritium gas. Bubbling a gas such as nitrogen through the solution is equivalent to boiling. Collect aqueous waste, assay it for radioactivity, and prepare an RSO-10 Request for Radioactive Waste Collection. Check frequently to ensure adequate hood operation. Bioassays are required when using more than 100 mci per week. NaBH 4 ( 3 H) should be stored in a desiccator that is to be opened only in a hood. The reagent will degrade more slowly if it is always kept dry. The use of a "dry bag" (such as glove bags purged with nitrogen) will increase the useful life of stock material and release less gas. 14

19 8. RADIATION MONITORING AND CONTROL a) Surveys Radiological surveys of areas where radioactive materials are used, stored or released are an essential part of a radiation safety program. Records of surveys are required by law and will be examined in each Authorized User's work area during State of Virginia, Division of Radiological Health inspections, external audits and inspections by Environmental Health & Safety. Records must be signed and dated. Survey records are the property of the licensee, not the individual user. A complete survey may include monitoring for fixed and removable contamination, exposure rate measurements and hazards evaluations. i. Fixed contamination is radioactive material that has bound with or leached into a surface and is not readily removable. This type of contamination is detected with a survey instrument able to detect the type and quantity of radioactive material present. Most common biomedical radioactive tracers can be detected with a thin window Geiger- Mueller survey instrument, with the exception of tritium. ii. Removable contamination is a greater potential hazard because it may be transferred from one place to another unknowingly. Wipe tests are used to obtain samples from surfaces potentially contaminated with radioactive material. A wipe, either a small filter paper or a cotton swab moistened with a solvent (water or isopropyl alcohol are commonly used) is wiped over the surface. The wipe is then prepared for counting in either a liquid scintillation or gamma counter. iii. Exposure rate or dose rate measurements must be made and recorded in areas where the potential for exposure to external sources exist. This excludes low energy beta emitters, such as 3 H, 14 C, 33 P, 35 S and 45 Ca, but includes 32 P, and gamma emitting sources. G-M detectors may be used for exposure rate measurements if they have been calibrated to the energy in question. Ion chamber instruments are best for measurement of exposure rate, although they are usually an order of magnitude less sensitive than G-M detectors. Ion chambers are also more accurate and can be made relatively energy independent. A thin crystal sodium iodide detector is most appropriate for 125 I surveys. iv. Hazard evaluations will be made periodically by the RSO, but all radiation workers must be alert for radiological and other hazards in the laboratory. v. Document surveys by making a diagram of the lab area and indicate all fixtures such as fume hoods, sinks, workbenches and freezers. Label areas with numbers and record counts at these numbers each time a survey is made. Sign and date the survey. Other kinds of surveys include air and water sampling as deemed necessary by the RSO, and monitoring shipping containers, both incoming and outgoing. The RSO will perform a survey of each Restricted Area no less than quarterly, and other surveys as needed. b) Periodic Survey Frequency Authorized User survey frequency is based on the radionuclide group and activity handled at one time. To determine frequency for your lab, identify the radionuclide by Group from the Group table below then identify the amount of activity handled at one time from the Survey Frequency category table. Individuals using 32 P and gamma emitting radionuclides are 15

20 required to perform an instrument survey of their work area and self at the end of each procedure. Radionuclide Groups (only representative radionuclides are listed that correspond to those likely to be used in this license. Other radionuclides in each group are the same as those listed in VAREG-EPI-720G, Appendix R.) Group 1 Group 2 Group 3 Group Ra 22 Na, 36 Cl, 45 Ca, 60 Co, 90 Sr, 125 I, 126 I, 131 I, 133 I, 137 Cs 14 C, 18 F, 32 P, 33 P, 35 S, 51 Cr, 57 Co, 63 Ni 3 H, 129 I Survey Frequency Category Group Low Medium High 1 <10 µci 10 µci to 1 mci >1 mci 2 <1 mci 1 mci to 100 mci >100 mci 3 <100 mci 100 mci to 10 Ci >10 Ci 4 <10 Ci 10 Ci to 1000 Ci >1000 Ci Survey Frequency is based on group and category: Low frequency surveys are conducted not less than once a month Medium frequency survey are conducted not less than once per week High frequency surveys are conducted not less than once per normal working day. c) Exemption from Survey If the following criteria are met and written approval by the Radiation Safety Officer is granted, periodic surveys performed by the Authorized User will not be required until radioactive materials are brought into the laboratory: i. The Authorized User has not received any Level 2 (written reprimand) Corrective Action Notices within the previous six months. ii. The last quarterly contamination survey performed by Environmental Health & Safety indicated that no removable contamination was present. iii. No radioactive material has been present or brought into the laboratory since the last quarterly contamination survey performed by Environmental Health & Safety this includes: Radioactive materials Radioactive samples Radioactive wastes To help ensure the effectiveness of the radiation safety program, the following laboratories cannot be exempted from the periodic survey requirements: i. Laboratories that have liquid scintillation or gamma counters. ii. Core laboratories or laboratories used as core labs that have space or equipment used for radioactive materials. 16

21 To take advantage of the survey exemption, the Authorized User must: i. Submit a written request for periodic contamination survey exemption to Environmental Health & Safety. The request must include: Authorized User s name Location building and room number ii. Continue performing periodic contamination surveys until written approval of the exemption is received from the Radiation Safety Officer. iii. The Authorized User must complete monthly documentation that no radioactive materials have been brought into or used in the laboratory under exemption using the RSO-5, Periodic Contamination Survey Exemption form. This documentation shall be kept with the contamination surveys in the Authorized User s radiation safety manual. iv. Submit a written notice to Environmental Health & Safety when radioactive materials use will resume in the laboratory under exemption. This must be received before radioactive materials may be ordered or brought into the laboratory. The notice must include: Authorized User s name Location building and room number When and what radioactive materials will be received d) Removable Surface Contamination Action Levels i. For removable surface contamination, an action level of 2,000 disintegrations per minute (DPM)/100 cm 2 above background is established for restricted areas, and an action level of any value over background for unrestricted areas will require decontamination to be performed and completed. After decontamination, a survey is required to document its effectiveness. ii. To find the background value by use of a handheld detector, turn on the detector in the area being surveyed and wait a few minutes while looking at the detector window. Read the meter, which is normally be in counts per minute (CPM). To convert CPM to DPM: DPM = CPM/efficiency of the instrument Areas such as fume hoods, glove boxes, and other containment facilities are exempted from these action levels. Contamination detected in unrestricted areas shall be immediately decontaminated to background levels. If it is not possible to achieve background level, removable contamination may not exceed the 2,000 DPM/100 cm 2 above background. If the spread of radioactive contamination is suspected, all work in the area shall be halted immediately. The RSO should be contacted as soon as possible. See Appendix A, Emergency Procedures. i. Fixed contamination in excess of these action levels requires action to reduce potential personnel exposure. These actions may include marking and placing shielding over the area or physically removing the contamination via a destructive process. 17

22 e) Exposure Rate Limits Exposure rates must be controlled within the action levels below. In Restricted Areas, the exposure rate may exceed the action level for short duration, as long as steps are taken to control the total dose equivalent within limits in Section 12. Barring the above exceptions, action must be taken to reduce the exposure rates as far as reasonably achievable below these levels. Area Action Levels Restricted 5 mrem/hour 100 mrem/40 hour Unrestricted 2 mrem/hour 100 mrem/year f) Survey Instruments Authorized Users will be required by the Radiation Safety Committee to have immediate access to suitable survey instruments such as G-M detectors. Such instruments will be maintained and calibrated as described in Section 9 of this manual. 18

23 9. INSTRUMENT CALIBRATION a) General Radiation detection instruments require at least annual calibration. The Radiation Safety Office will maintain records of instrument calibration. b) Calibration i. Calibration of survey meters shall be performed with radioactive sources such that the: Sources are approximate point sources. Source activities are traceable within 5% accuracy to the National Institute of Standards and Technology (NIST) calibrations. Calibration frequency is at least annually. Readings should be taken at two points on each scale (approximately! and # of full scale, " " respectively.) Instrument reads within + 20% of true value. Read the appropriate section of the instrument manual to determine how to make necessary adjustments to bring instrument into calibration. ii. Sources of 137 Cs or 60 Co are appropriate for the performance of calibration. The instrument must be calibrated at lower energies if its response is energy dependent and it is to be used to measure 125 I, 133 Xe, or 99 Tc-m. This calibration may be done either: With calibrated standards of radionuclides at or near the desired energies, or As a relative intercomparison with an energy independent instrument and uncalibrated radionuclides. c) Pulser Calibration This is a calibration method for counts per minute (CPM) survey instruments used for detecting and measuring contamination levels: i. Introduce pulses into circuit at connection to radiation detector. Pulses should be similar to those produced by actual ionizing events. ii. Adjust instrument to + 20% when measured at two points on each scale of the instrument (approximately! and # of full scale recommended). This will set the linearity on all " " ranges. iii. After linearity is set, reattach detector and use calibrated beta sources of various beta energies to determine efficiency of the instrument for each energy desired. Use long halflife beta sources as appropriate. iv. A plot of beta energy (maximum) versus instrument response (efficiency) can be made if desired. v. Beta sources that produce 2,000 to 5,000 CPM are sufficient; the Pulser will be used to check the low and high ranges. 19 Calibration Expenses EH&S will calibrate instruments within the limits of their capability. If an instrument needs to be calibrated or repaired by a third-party, all costs are the responsibility of the User.

24 d) Reference Check Source A reference check-source of long half-life, e.g., 137 Cs, shall be also read at the time of the above calibration. The reading shall be taken with the detector placed in close proximity (contact) to the check source. A reading of this reference check source should be taken: i. Before each use ii. After each maintenance and/or battery change iii. At least quarterly If any reading is not within ±20% of the reference check source reading, the instrument should be operationally checked and recalibrated as necessary. 20

25 10. RADIATION DOSE LIMITS a) General Use of radioactive material and radiation-producing machines may result in employee exposure to radiation. Procedural and administrative radiation protection practices are developed to minimize radiation dose to employees as well as members of the general public in unrestricted areas. Application of these dose limits will ensure that individuals do not exceed levels of acceptable risk from radiation exposure. In all cases, the objective is to keep radiation dose As Low As Reasonably Achievable (ALARA). b) Adults Radiation dose shall be controlled such that the limits listed below are not exceeded, except in the case of planned special exposures. It is unlikely that a planned special exposure would be permitted; however, in the event planned special exposures are deemed necessary, the conditions of 12VAC must be met. c) Minors Area Measured Limit per year (rem) Total effective dose equivalent or, 5 Sum of deep dose equivalent and the committed dose equivalent to any individual organ or tissue 50 Eye 15 Shallow dose equivalent to skin or extremity 50 The annual occupational dose limits for minors are 10 percent of the dose limits for adults. A minor is defined as an individual less than 18 years of age. d) Dose to Embryo/Fetus Women who declare their pregnancy are offered additional protection to their developing fetus. The limit is 500 mrem Total Effective Dose for the declared gestational period. This reduction is due to the increased sensitivity of rapidly developing cells. Efforts to maintain exposure less than 0.05 rems per month will ensure the total dose remains within the limit. To declare a pregnancy, the pregnant worker must notify the Radiation Safety Officer in writing. Counseling by the Radiation Safety Officer will be offered and includes topics regarding dose limits for the term of pregnancy and risk factors from NRC Regulatory Guide 8.13 Instruction Concerning Prenatal Radiation Exposure. The RSO will also assess her potential external and internal dose based on the type and quantities of radionuclide used in her work. The declared pregnant worker will be automatically assigned a secondary abdomen dosimeter. The results of her monitoring will be reported on a monthly basis throughout the remainder of the gestation period. 21

26 e) Individual Members of the Public Dose to members of the public, such as visitors, shall be kept as low as reasonably achievable, but not to exceed 0.1 rem per year, exclusive of dose contribution from sewer disposal of radioactive materials. Additionally, the dose in unrestricted areas from external sources shall not exceed rems in any one hour. f) Internal Dose The majority of radionuclide manipulations at EVMS present minimal likelihood for inhalation or ingestion of radionuclides; therefore, internal occupational doses are not anticipated. In event a protocol or procedure contains a potential for an occupational intake, actions will be initiated by the Authorized User to ensure the intake doesn't exceed two percent of the Allowable Limit on Intake (ALI). Respirator protection factors shall not be used to determine compliance with this limit. g) As Low as Reasonably Achievable Guidelines Radiation dose limits are established to ensure occupational workers and the general public receives minimal radiation exposure. Most operations at EVMS are readily accomplished within these limits; however, administrative dose guidelines are established to further reduce exposure and to alert the individual and EH&S to potential situations where unnecessary dose may be received. Radiation exposure is minimized through proper planning, use of containment and shielding, and application of good radiation protection practices. It is further minimized when radioactive material and radiation producing machines are used by faculty and staff with training and experience in its use and frequent consultation between users and EH&S personnel. EVMS Clinical ALARA Warning Levels (mrem/year) Level 1 Level 2 Monthly Quarterly Monthly Quarterly Annual Limit Whole Body ,000 5,000 Any Organ 2,500 6,250 3,750 10,000 50,000 Skin 2,500 6,250 3,750 10,000 50,000 Extremity 2,500 6,250 3,750 10,000 50,000 Lens of Eye 750 1,875 1,125 3,000 15,000 EVMS Non-Clinical ALARA Warning Levels (mrem/year) Level 1 Level 2 Monthly Quarterly Monthly Quarterly Annual Limit Whole Body ,000 Any Organ 417 1,250 1,250 3,750 50,000 Skin 417 1,250 1,250 3,750 50,000 Extremity 417 1,250 1,250 3,750 50,000 Lens of Eye ,125 15,000 All units are in mrem 22

27 i. External Exposure. Two Investigational Levels are set to alert EH&S and the individual of their dose received during the dosimeter-wearing period: Level 1, the RSO will send a memo to the individual, advising them of their dose. Level 2, the RSO will send a memo to the individual, advising them of their dose and they are required to respond to a questionnaire regarding their work practices that led to the accumulation of dose. ii. Internal Exposure. Prudent use of in vivo and in vitro bioassays ensure that work practices minimize intake of radionuclides. In the event bioassays reveal an intake, the magnitude of the intake will dictate further evaluation or investigation. For intakes that are 0.02 times ALI further evaluation is conducted that includes at least two additional bioassay measurements and a review of procedures that may have resulted in the intake. Example: 125 I 40 µci x 0.02 = 0.8 µci or 800 nci) 40 µci x 0.1 = 4 µci In event the intake is greater than 0.1 times ALI, a thorough investigation consisting of additional bioassay measurements will be performed to obtain sufficient data to determine excretion and retention functions and quantify the initial intake. These measurements and results will be retained permanently as part of the individual s dosimetry record. 23

28 11. POSTING AND LABELING The presence of radioactivity or radiation fields is identified by use of the standard radiation symbol, a magenta three-bladed (tre-foil) design on a yellow background. Rooms, areas, or equipment where radioactive materials are used or stored shall be clearly marked with radiation signs and labels to alert individuals to their presence. a) Posting Signs i. Very High Radiation. An area in which an individual could receive an absorbed dose in excess of 500 rad in 1 hour. This area shall be posted with a radiation sign containing the words "GRAVE DANGER, VERY HIGH RADIATION AREA." ii. High Radiation Area. An area in which an individual could receive a dose equivalent in excess of 100 mrem in 1 hour at 30 centimeters (12 inches) from source. This area shall be posted with a radiation sign containing the words, "CAUTION, HIGH RADIATION AREA," or "DANGER, HIGH RADIATION AREA." iii. Radiation Area. An area in which an individual could receive a dose equivalent in excess of 5 mrem in 1 hour at 30 centimeters (12 inches) from the source. This area shall be posted with a radiation sign containing the words "RADIATION AREA." iv. Radioactive Materials. Rooms or areas where radioactive material is used or stored in quantities exceeding 10 times the amounts listed in 12VAC shall be posted with a radiation sign containing the words "CAUTION RADIOACTIVE MATERIAL," or "DANGER, RADIOACTIVE MATERIAL." Examples are rooms containing activity greater than 10 mci of 3 H, 1 mci of 35 S, 0.1 mci of 32 P or mci of 125 I. b) Exceptions to Posting Signs i. Caution signs are not required if rooms or areas contain: Radioactive material for less than eight hours per day, and the room is constantly attended by an individual trained in radiation protection practices. Sealed sources where the radiation level at 30 centimeters from the surface of the container is 5 mrem per hour or less. Posting Summary Very High Rad Area = >500 rad/1 hour High Rad Area = >100 mrem/1 30 cm Rad Area = >5 mrem/1 30 cm RadMat = >10x listed quantities 24