RADIATION SAFETY
PROGRAM
Revised July 26, 2004
Section II--Radiation Safety Program
1.Design and Purpose of the Radiation Safety Program
2.Personnel Involved in the Use of Radioactive Material
I.Design and Purpose of the Radiation Safety Program
A.Purpose of the Radiation Safety Manual
This manual is designed to provide information to personnel and the general public regarding the structure of Youngstown State University's (YSU) Radiation Safety Program. It presents those procedures adopted by the U.S. Nuclear Regulatory Commission (NRC), the Ohio Department of Health, and YSU as safe, reasonable, and enforceable. Although this manual is not submitted as part of our application for a Byproduct Material License, it is designed to conform closely to the Code of Federal Regulations 10 CFR 20 entitled, "Standards for Protection Against Radiation". Similar regulations of the Ohio Department of Health are also specified by the Ohio Administrative Code (Chapters 3701-38, 3701-39, 3701-40). Copies of these regulations are on file in the Radiation Safety Office, located in the Department of Environmental and Occupational Health and Safety, Room 2046, Cushwa Hall. Since Ohio became an agreement state in April of 1999, YSU is licensed by the Ohio Department of Health Bureau of Radiation Protection.
B.The ALARA Goal
The chief goal of the YSU radiation safety program is to minimize the exposure to radioactive materials and their radiation to a level AS LOW AS IS REASONABLY ACHIEVABLE (ALARA). There are three objectives to an effective ALARA program.
1. To reduce occupational radiation exposure to levels reasonably achievable by means of good radiation protection planning and practice.
2. To reduce radiation exposures to the general public to levels as low as is reasonably achievable.
3. Commitment of management to encourage good radiation safety planning, to establish and enforce radiation safety practice, and to remain vigilant to the goal of improving the radiation safety program.
C.Administrative Line of Authority
1. Radiation Safety Officer (RSO)
The Radiation Safety Officer is vested with the responsibility and authority to administer and enforce the regulations of the Ohio Department of Health. The RSO is charged with making the ultimate institutional decisions regarding all aspects of the radiation safety program. The RSO has the full authority to immediately halt any activity judged to be a threat to health, safety, or the environment; or a violation of the Commission's regulations or the conditions of the license. The RSO reports to the Vice President for Administration and performs the following duties:
a. General surveillance of all health physics activities, including both personal and environmental monitoring.
b. Furnishing consulting services to personnel at all levels of responsibility on all aspects of radiation protection.
c. Receiving, delivering, and shipping all radioactive materials coming to or leaving the YSU campus.
d. Monitoring of all materials, devices, or equipment capable of producing ionizing radiations.
e. Receiving, reviewing, and approving all applications for the use of radiation sources to determine if the proposed work can be safely accomplished within the existing licensed procedures and isotope possession limits.
f. Instructing personnel in proper procedures for the use of radioactive materials.
g. Approving all purchase requisitions for radioactive materials assuring that receipt of the ordered material will not exceed the license possession limits.
h. Administrating the waste disposal program. Obtaining and keeping all Federal, State, and Local waste disposal records and permits.
i. Performing leak tests on all sealed sources at minimum 6 month intervals.
j. Maintaining an inventory of Radiation Safety detection equipment in proper working order and recalibrated on an annual basis.
k. Maintaining a current inventory of radioactive materials on campus to be updated on a monthly basis.
l. Storing radioactive materials not in current use.
m. Maintaining permanent records of:
- personnel occupational exposures
- receipt of radioactive materials
- disposal of radioactive materials
- laboratory monitoring
n. Maintaining central storage and waste facilities.
o. Performing air quality and ventilation surveys of radioisotope areas as needed.
p. Performing periodic audits of laboratory inventories and monitoring records.
q. Maintaining an inventory of calibrated survey instruments to be distributed to investigators as needed.
The RSO will meet with the Vice President for Administration on a monthly basis and will review with him all aspects of the radiation safety program as it relates to the University’s ODH licenses.
2. The Radiation Safety Committee
The Radiation Safety Committee performs the following functions:
a. Provides advice to the RSO on policies and technical matters regarding radiation safety.
b. Receives and reviews periodic reports from the RSO on monitoring, contamination, and personnel exposure.
c. Conducts annual audits of the Radiation Safety Program to determine that all necessary functions are being performed at their required intervals, and all required records are intact. They will report their finding to the Executive Vice President. Reports of all audits will become part of the radiation file.
3. YSU Policy Governing Violations of ODH Regulations
The RSO has the right to fully investigate a possible hazard at any time. The RSO has the authority for making the final institutional decisions regarding violations of ODH or YSU regulations involving the safe handling of radioactive materials. Violations of safety regulations can range from the incidental to being life-threatening. The RSO will determine the severity of the violation and the appropriate prompt action. The RSO has the right to immediately terminate any activity found to be a threat to health or property. Those individuals committing serious violations or frequently violating safety standards will have their privilege to use radioactive materials revoked.
If necessary, individuals may appeal a decision to the Radiation Safety Committee. In the event of a disagreement between the RSO and the Radiation Safety Committee, representatives of the ODH will be contacted to review the situation.
II.Personnel Involved in the Use of Radioactive Material
This section discusses the requirements for participation in the radiation safety program, and outlines the training and responsibilities of each person in the program.
A.Authorized Users
All users who desire to use radioisotopes or other forms of ionizing radiation must provide a summary of their past training and experience in handling radioactive materials (see Appendix A). This summary must be submitted to the ODH in order to authorize new investigators. The RSO will prepare the necessary license amendment for submission to the NRC.
Authorized users are responsible for the health and safety of all personnel in their laboratory. They must ensure that procedures used to accomplish the intended research goals are as safe as possible. They are responsible for:
1. Determining that all individuals working in their laboratory have completed the required training programs before beginning to handle radioactive materials.
2. Assuring that all personnel working in their laboratory are included in the personnel monitoring program if necessary.
3. Monitoring their laboratory's ambient conditions as often as necessary to determine that exposure to radiation is maintained ALARA.
4. Labeling of all areas and materials with the proper warning signs, and assuring that the information is kept current and accurate.
5. Properly disposing of radioactive wastes and preventing the accumulation of excessive quantities of waste material in the laboratory.
6. Notifying the RSO of any changes in personnel, techniques, or physical facilities from those outlined in their original approved procedures.
B.Authorized Assistants (Technical Staff)
All individuals who desire to use radioisotopes or other forms of ionizing radiation under the supervision of an authorized user must provide a summary of their past training and experience in handling radioactive materials (see Appendix A) to the RSO. The RSO will review the credentials and determine whether or not they are sufficient and require them to pass a written examination.
Authorized assistants must work under the supervision of an authorized user. Authorized assistants will be responsible for setting up and completing their experiments in as safe a manner as possible. They shall report all unsafe conditions to the authorized investigator responsible for that area or the RSO.
C.Students
All Students will work under the direct supervision of an authorized user
Before students are allowed to handle radioactive materials, the following procedures shall be completed:
1. The specific procedures to be conducted by the students must be submitted to the RSO for review and approval;
2. The Radiation Safety Rules and General Safety Rules for Laboratories must be distributed and reviewed;
3. The specific techniques to be performed must be demonstrated;
4. The techniques for monitoring facilities and personnel must be demonstrated;
5. The procedures for the proper disposal of all generated wastes must be reviewed, and;
6. The procedures for handling spills or other emergency events must be reviewed.
D.Ancillary Personnel
All ancillary personnel (e.g., security, cleaning, maintenance, etc.) who enter laboratories containing radioactive materials will be trained on current policies and procedures at the beginning of their employment and annually updated thereafter. Topics to be covered include:
1. the types and locations of all radioactive materials on campus;
2. the specific radiation signs and labels used on campus;
3. routine safety procedures for working in radioactive materials areas, and;
4. specific procedures to follow in the event of an emergency involving radioactive materials.
In addition, receiving personnel will receive similar instructions including:
1. how to recognize packages containing radioactive materials;
2. the general procedures to follow for receiving packages and notifying the radiation safety office;
3. the specific procedures to follow in emergencies involving damaged packages.
Formal lecture presentation supplemented with audiovisual material will be employed during the training sessions. The RSO will perform all training.
A. Authorization of Radioactive Materials Locations
All rooms in which radioactive materials or radiation producing equipment is used or stored must be specifically approved for that purpose by the ODH. The RSO will prepare the necessary license amendment for submission to the ODH.
Approval will consider the isotope to be used, the maximum activity expected, the volatility and dispersibility of the radioactive materials, and the specific procedures to be carried out in the area. Other factors which may influence a decision are the amount of bench space, fume hoods, bio-hoods, shielding, storage space, and waste handling facilities.
All rooms approved for use of radioactive materials must also be under the direct control and supervision of an investigator authorized for radioisotope usage. The investigator must accept full responsibility for continual safe conditions in that laboratory.
The use or storage of radioactive materials in shared departmental facilities must also be approved by the Departmental Chair. The authorized investigator is responsible for informing all departmental members in writing of the intention to use or store radioactive materials, and of any special precautions that need to be taken.
Definitions: Areas are defined as follows:
1. Unrestricted Area - "means an area, access to which is neither limited nor controlled by the licensee."
2. Restricted Area - "means an area, access to which is limited by the licensee for the purpose of protecting individuals against undue risks from exposure to radiation and radioactive materials."
3. Controlled Area - "means an area, outside of a restricted area but inside of the site boundary, access to which can be limited by the licensee for any reason."
4. Radiation Area - "means an area, accessible to individuals, in which radiation levels could result in an individual receiving a dose equivalent in excess of 0.005 REM (0.05 mSv) in 1 hour at 30 centimeters from the radiation source or from any surface that the radiation penetrates."
5. High Radiation Area - "means an area, accessible to individuals, in which radiation levels could result in an individual receiving a dose equivalent in excess of 0.1 rem (1 mSv) in 1 hour at 30 centimeters from the radiation source or any surface that the radiation penetrates."
6. Very High Radiation Area - "means an area, accessible to individuals, in which radiation levels could result in an individual receiving an absorbed dose in excess of 500 rads (5 grays) in 1 hour at 1 meter from a radiation source or from any surface that the radiation penetrates."
All areas using radioisotopes will be classified as Unrestricted Minimum Quantity, Controlled Type C, Restricted Type B, or Restricted Type A according to the tables found in Appendix B. Laboratories will be restricted to the maximum allowable activities indicated.
All laboratories which do not control the access of non-occupational personnel at all times (e.g., unauthorized students, technicians, secretaries, etc.) will be held to a 0.1 modifying factor for maximum permissible quantities. Only those areas which control the access of non-occupational personnel will be allowed to operate at the full levels.
Accordingly, YSU radioisotope laboratories will be regulated as Controlled Type C areas.
If the need arises to designate areas as Restricted Type B or Restricted Type A laboratories the RSO will amend the by-product materials license accordingly.
B. Before Beginning an Experiment in an Approved Area.
Before working with radioactive materials, all personnel must be authorized as outlined in Section 2 and have arranged for personnel radiation exposure monitoring including bioassay if necessary. The authorized investigator supervising the research project is responsible for the health and safety of all personnel on the project. The investigator must be certain that all requirements and preparations have been met before assigning someone to work with any radioactive materials or radiation producing equipment. All personnel must also know how to contact the RSO in the event of an emergency, and be familiar with the emergency procedures outlined in Section 6.
Before attempting any new procedures with radioactive materials a "dry run" must be carried out to help anticipate possible hazards during the experiment. An aid in detecting potential flaws is to perform the experiment with a fluorescent material or dye. Ultraviolet light will be used to survey the area following an experiment to help indicate where materials may have contaminated the area.
C. Purchasing Radioactive Materials
All purchase requisitions for radioactive materials must be entered into the CUFS1 system . Requisitions will be processed in approximately 24-48 hours. If you require special processing of your order, contact the radiation safety office and give them the requisition number after it has been entered into CUFS.
Blanket purchase orders can be arranged for those investigators requiring frequent shipments of identical materials. Purchase orders covering the desired number of shipments are processed as usual through the Radiation Safety and Accounting Offices. Unless the Purchase Order states specific dates for each of the shipments, the RSO must approve all subsequent shipments. This is necessary to insure that all materials will be properly received, and that receipt of material will not exceed licensed limits.
1The CUFS (College and University Financial System) is a computerized purchasing package used by many State Colleges and University. No radioactive materials may be ordered without approval from the Radiation Safety Officer.
D. Receiving Radioactive Materials1
1. Receipt During Normal Working Hours
All packages containing radioisotopes will be delivered to the Chemical Management Center (CMC). Central Receiving will not accept packages containing radioisotopes but will refer the transit company to the CMC for delivery
When a package of radioactive material arrives on campus, the CMC personnel will inspect the package for signs of damage (i.e., crushed box or wet areas due to leaks) before accepting it from the carrier. If the package appears damaged, the CMC personnel must contact the RSO immediately. The RSO will monitor the package, the receiving area, the carrier's vehicle, and all personnel who handled the package to determine the extent of possible contamination.
If the package is received in good condition, the receiving personnel will sign for its receipt and immediately notify the Radiation Safety Office of its arrival. As soon as possible, Radiation Safety personnel will pickup the package at the CMC and complete a "Receipt of Radioactive Materials Form" (see Appendix C). The receipt form and packing slip will be retained for inspection by the ODH. All packages will be placed in a special locked cabinet bearing radiation signage until picked up by the RSO. Only CMC personnel and the RSO will have keys to the cabinet.
Inspections of the package must be performed in accordance with 10 CFR 20 as follows:
"Each licensee shall monitor the external surfaces of a package known to contain radioactive material for radioactive contamination and radiation levels if the package:
a. is labeled as containing radioactive material; or
b. has evidence of potential contamination, such as packages that are crushed, wet, or damaged."
This will normally include all Radioactive Material-Excepted Limited Quantity, N.O.S.; Radioactive White I; Radioactive Yellow II; or Radioactive Yellow III packages.
Monitoring shall consist of surveys and wipe tests using approved instruments and techniques. Wipe tests shall be performed by wiping a 300 cm2 area of the exterior package with filter paper disks moistened in 50%-70% ethanol. Surveys shall be performed with calibrated instruments and recorded in mR/hr. If removable contamination in excess of 10-5 uCi/cm2 (22 dpm/cm2 or 6,600 dpm for 300 cm2); or radiation dose levels in excess of 200 mRem/hr at the surface or 10 mRem/hr at 1 meter are detected, the RSO will immediately notify the final carrier and the ODH.
All radioactive packages must be inspected and wipe tested as soon as possible, but no later than 3 hours from the time of arrival on campus.
1
The RSO will inform the Chemical Management Center when a shipment of radioactive materials is expected to arrive on campus.2. Receipt After Working Hours
The Chemical Management Center (CMC) is staffed between 7:30 and 4:30 weekdays. No shipments are received by the University before or after these hours. Delivery personnel must arrive during working hours, or return the next day.
E. Storage
All radioactive materials must be stored in an area of controlled access to prevent unauthorized removal. The area must be locked when personnel authorized to handle the material are not present. Only approved laboratory areas will be used for storage.
The authorized investigator is responsible for assuring that all items containing radioactive material are marked with an approved label bearing the isotope symbol and the words "Caution Radioactive Material." Items used in core facilities must also bear the investigators initials.
F. Use
All radioactive materials must be handled in approved areas. Radioactive materials should be treated as hazardous substances and handled with all cautionary procedures normally accorded such substances. Normal precautions should include the following safety measures.
1. All orders for radioactive materials must be approved by the RSO.
2. All use of radioactive material must be supervised by an authorized user.
3. All radioactive waste must be placed in appropriate containers in accordance with licensing requirements.
4 No eating, drinking, smoking, applying cosmetics, or any other procedure that could lead to inadvertent ingestion of radioactive materials is permitted.
5 Film badges must be worn when using gamma ray, x-ray, or high energy beta producing isotopes or equipment.
6 Clothing should be disposable in the event of a major spill. Lab coats and disposable gloves should be worn when handling radioactive materials. Care must be taken not to contaminate other surfaces when working with gloves. Traces of radioactive material are often inadvertently transferred to refrigerator handles, telephones, sink faucets, centrifuge doors and rotors, and instrument dials when handling them with a "hot" glove. Be sure to monitor such surfaces following use to assure no contamination has taken place. Potentially contaminated clothing is not to be worn out of the laboratory area.
7. Glassware, tongs, pipettors, and other similar materials used for radioisotope work should be suitably marked and must be decontaminated before being used in a non-radioactive area. "Hot" glassware should be disposed or decontaminated promptly.
8. Work should be confined to as small an area as possible. This simplifies the problem of confinement and shielding, and aids in limiting the affected area in case of an accidental contamination.
9. All work involving the likelihood of aerosols, dusts, or gaseous products, must be done in hoods, glove boxes, or similar protective devices. All releases from these systems shall be ALARA, and may never exceed the maximum permissible concentration in air outlined in 10 CFR Part 20.
10. Work surfaces should be covered with an absorbent paper with waterproof backing. Procedures involving high activity liquids should be confined to an impervious tray. Change paper and wash trays frequently to prevent the spread of radioactive contamination.
11. Pipetting radioactive materials by mouth is prohibited.
12. Food or drink, even in sealed containers, must not be stored in the same refrigerator or freezer where radioactive materials are stored.
13. Each laboratory or area utilizing high energy beta, gamma or x-radiation shall be equipped with a portable survey meter available from the Radiation Safety Office. Work and storage areas should be monitored before, during, and after an experiment to detect contamination and to maintain exposure levels within the allowable limits.
14. Minimize the exposure to high activities of gamma, x-ray, and high energy beta emitting radioisotopes. Confine such isotopes to a suitably shielded storage box in a remote spot of the laboratory (e.g., back corner of a hood or refrigerator). Use long handled forceps or tongs when possible to reduce hand exposures.
15. Any equipment used with radioactive materials (refrigerators, ovens, centrifuges, lyophilizers, vacuum pumps, etc.) shall not be removed from its authorized area until demonstrated to be free of contamination. No potentially contaminated equipment shall be repaired by maintenance or other personnel without first being demonstrated to be free of contamination prior to servicing. These regulations also apply to any equipment being returned to the manufacturer for servicing.
G.Animal Use
No animals are permitted to be used in experiments involving radioisotopes unless this license is amended by the Ohio Department of Health. Licensed Users anticipating the need to use animals in their work with radioisotopes should discuss their plans with the RSO and a license amendment must be approved by the Ohio Department of Health before any work begins.
Some guidelines that must be considered when planning experiments using radioisotopes in animal investigations are:
1. The authorized investigator is responsible for assuring that all personnel are trained in the proper safety precautions to be exercised in conjunction with the experimentation.
2. Radioactive materials may only be administered to animals owned by the university. All animals must be identified to insure proper identification and disposal.
3. All cages containing treated animals must be labeled with radioactive warning tape. The door to the room containing the cages must also be labeled and locked when not under direct supervision. The authorized investigator is responsible for monitoring, and if necessary decontaminating equipment used in their experimentation.
4. All dead animals must be treated as radioactive waste. Feces and urine from animals must also be treated as radioactive unless proven otherwise. Contact the Radiation Safety Office for details on disposal.
5. Possible hazards resulting from air concentrations of radioactive metabolites must be controlled. Metabolic cages may be required in order to meet safety standards.
H.Inventory
The RSO is responsible for maintaining inventory records of all radioactive materials on campus, and insuring that the possession limits for each specific isotope are not exceeded. Authorized investigators are responsible for maintaining up-to-date records of the receipt, use, and disposal of radioactive materials under their supervision.
The RSO will receive from each investigator a radioisotope inventory form (Appendix D) indicating the activity of each radioisotope under their supervision at the beginning of the month. The RSO notes the activity of any isotopes received through the office during that month and calculates the activity of each isotope lost by decay using the following formula. (Note that the duration of a month is taken as 30.5 days, an annual average number of days per month.)
A=Aoe( -.693 x 30.5)
T˝
On receipt of their inventory form, each investigator is responsible for promptly completing the information on the form and returning it to the RSO. All entries should be made in millicuries.
Materials transferred from one investigator to another should be noted in the transferred column of the form. Investigators may not transfer radioactive materials to other investigators without the approval of the RSO.
The RSO records the receipt, disposal, and decay of each isotope onto Master Inventory Forms. The RSO must ascertain that the receipt, storage, disposal, and
decay balance to the nearest microcurie. The RSO will compare the total activity present on campus with the possession limits for each specific isotope in order to assure license compliance.
I. Transportation of Radioactive Materials Off Campus
Limited quantities of radioactive materials may be transported off campus to another facility licensed by the NRC to receive the radioactive material (e.g., to one of the consortium universities or hospitals). Due to the numerous NRC and DOT regulations governing transportation of these materials on public highways, ALL TRANSPORTATION OFF CAMPUS MUST PROCEED THROUGH THE RADIATION SAFETY OFFICE. Transfers will only be arranged from the Radiation Safety Office of the YSU campus to the Radiation Safety Office of the other institution. All transfers must comply with all applicable regulations found in 10 CFR 71 and 49 CFR 173.
The goals of the monitoring program are to assure the safe working conditions for all personnel in restricted and unrestricted areas. Frequent monitoring of laboratories and personnel helps to assure that individuals will not exceed their maximum permissible exposure limits, and that radiation levels remain as low as reasonably achievable (ALARA).
The RSO will maintain all required records of personnel occupational exposure histories and laboratory working conditions.
A. Personnel Film Badge Dosimetry Program
YSU contracts with an accredited firm for a monthly radiation film badge program. The standard badge given to personnel is a "whole body" badge. Special ring or wrist badges are available for situations in which hand exposures may be excessively high compared to whole body exposures. They are specifically required when handling > 1 mCi of strong beta or gamma emitters. Doses are reported monthly to the Radiation Safety Office. Any individual receiving a dose above background levels (10 mR/month) will be notified immediately.
Who should wear a film badge?
All individuals handling x-ray, gamma-ray, or high energy beta emitting isotopes (e.g., 125I, 60Co, 32P) or x-ray producing equipment must wear a film badge. Individuals working exclusively with low energy beta emitters (eg., 3H, 14C) need not wear a badge. Finger extremity monitoring badges must be worn when working with 32P having an activity of 1.0 millicurie or more.
The Radiation Safety Office also has a limited number of "spare" badges which may be issued in emergency situations (i.e. when individuals not normally issued a badge, such as maintenance personnel must enter radiation areas to perform maintenance work).. Individuals issued "spare" badges will become part of the following months dosimetry report. Badges can usually be obtained in 48 hours if a special need arises. The maximum permissible exposures for YSU personnel are as follows:
Maximum Annual Permissible Dose
Type of Dose
REM
Sieverts
Total Effective Dose 5.0
0.05
Sum of Deep Dose and Equivalent Committed Dose to Organs other than the eye. 50
0.5
Dose Equivalent to the eye. 15
0.15
Shallow Dose Equivalent to skin or extremities 50
0.5
Declared Pregnant Women (9 Month term)
Dose Per Month.5
.050.005
.00051 Taken from 10 § 20.1201 and Reg. Guide 8.13
Members of the General Public
All exposures above minimal (minimal is less than 10 mRem) will be reported to the individual as soon as they are detected. The RSO will attempt to determine the cause of the exposure and try to eliminate it. In the event of whole body exposure greater than 200 mRem/month, the RSO will notify the individual exposed, the authorized investigator responsible for the individual, and the chair of the The Radiation Safety Committee. If deemed necessary, a meeting of the The Radiation Safety Committee will be scheduled. All concerned will attempt to determine the cause of the exposure and take corrective measures. Corrective measures may include revision of laboratory procedures, construction of additional shields, and/or suspension of the use of radioisotopes by the individual for the remainder of the calendar quarter.
All individuals have the right to examine their exposure reports at any reasonable time in the safety office. Future employers of the individual have the right to obtain a copy of their exposure history.
B. Bioassay Programs
The bioassay program is designed to assure that no radioactive material has been inhaled, absorbed, or ingested during the handling of specific radioisotopes under certain conditions. Appropriate clinical action will be taken if certain levels of radioactive materials are detected.
Bioassays are performed on an "as needed" basis, and are only required under certain circumstances. YSU's policy is to minimize as much as possible those situations requiring bioassays.
Who must be bioassayed?
Monitoring for intakes is required for individuals handling quantities of radionuclides where there is a likelihood that the individual might receive greater than 10% of the Annual Limits of Intake (ALI)
It is anticipated that seldom, if ever, will activities involving radioisotopes other than 3H or 125I require bioassay. However, all experiments involving the use of radioisotopes will be evaluated prior to conducting the experiment by the RSO, the authorized user, and the Radiation Safety Committee to determine whether or not bioassay is indicated. If it is determined that bioassay is necessary, a protocol will be developed and submitted to the ODH for their approval prior to conducting the experiment.
Experiments involving 3H nucleotide precursors at levels exceeding the table found in Appendix E shall be performed in a radiological fume hood and investigators will wear lab coats throughout the experiment. The RSO shall be notified at least 8 hours before such an experiment and will be present during all new procedures involving the use of 3H. In addition, a "dry-run" as described in item 3B on page 9 of this manual must be performed prior to conducting any new experiments involving the use of 3H.
Urinalysis will be performed within 48 hours following the use of designated quantities of 3H compounds. Duplicate 1 ml samples of urine will be collected and counted by liquid scintillation using an appropriate cocktail. If routine use of designated quantities of isotopes are planned, urinalysis will be performed biweekly until one month after use of 3H at designated levels has ceased.
If 3H excretion rates exceed 50 uCi/liter the following steps will be taken:
1. Immediately refer the individual to the Nuclear Medicine section of Saint Elizabeth Hospital (Youngstown, Ohio).
2. Report the incident to the ODH..
3. Notify the Authorized Investigator in charge of the area and the Chemical Hygiene Committee Chair.
4. Investigate the operation and the area it was performed in to determine the cause of the exposure.
5. Implement corrective procedures necessary to reduce further exposures. These may include removing the individual from further work with excessive quantities of 3H or prohibiting use of excessive quantities of 3H in that work area.
6. Perform urinalysis on a weekly basis until excretion rates of less than 5 uCi/liter are seen for 2 consecutive weeks.
In the event that activities of 5 - 50 uCi/liter are observed, the urinalysis procedure will be repeated within 48 hours. If levels are still above 5 uCi/liter, steps 3 - 6 will be implemented.
The activity levels above which bioassay shall be required for 125-I are shown in Appendix F. The thyroid burden for each individual will be determined by scanning each participant with an Eberline model ESP-1 survey meter equipped with low energy scintillation probe. The meter will be calibrated against a known standard enclosed in a Lucite neck phantom to simulate tissue equivalency and thyroid position. Readings will be taken from the neck over the thyroids and compared with control readings taken from the individual's thigh. These values will be used to estimate the individual's thyroid burden.
A description of the Eberline ESP-1 can be found in Appendix G of this manual.
Bioassays will be performed at the following frequencies:
1. Initial - Preoperational baseline reading performed within 2 weeks prior to beginning work with radioactive iodine.
2. Routine - Performed at the frequencies listed in NRC 8.20, Regulatory Position 4. Initially, bioassays will be performed within 72 hours following entry of an individual into an area where bioassays are required, but waiting at least 6 hours for distribution of a major portion of the iodine to the thyroid. For individuals who are continually using radioactive iodine, bioassays will be performed at a minimum of every 2 weeks thereafter. For individuals who use radioactive iodine on an infrequent basis (less than every 2 weeks), bioassays will be performed within 72 hours (but no sooner than 6) of the end of the work period. After a 3 month measurement period, the frequency of bioassays for continual users can be reduced to monthly or quarterly periods if criteria outlined in NRC 8.20 are met.
3. Postoperational - A bioassay will be performed within 2 weeks of the last possible exposure of radioactive iodine when the individual is terminating all potential exposure.
4. Diagnostic - Follow up bioassays will be performed within 2 weeks of any measurement exceeding levels given as action points in NRC 8.20 regulatory position 5-1, and within 1 week for levels exceeding those given in 5-2.
5. Emergency - Bioassay will be performed on all individuals as soon as possible after any incident that might cause thyroid uptakes to exceed
Whenever the thyroid burden is found to exceed 0.12 uCi of 125-I the following steps will be taken by the RSO:
1. Conduct an investigation of the operations involved to determine the cause of the exposure, and evaluate the potential for further exposure.
2. Implement corrective action to eliminate or reduce the potential for further exposures.
3. Repeat bioassays within 2 weeks to confirm the presence of radioactive iodine and estimate the effective biological half-life.
4. Notify the Ohio Department of Health.
If the thyroid burden is found to exceed 0.5 uCi of 125-I the following actions will be taken immediately:1. Refer the individual to the Nuclear Medicine section of Saint Elizabeth Health Center (Youngstown, Ohio).
2. Conduct an investigation of the operations involved to determine the cause of the exposure, and evaluate the potential for further exposure.
3. Implement corrective action to eliminate or reduce the potential for further exposures.
4. Notify the Ohio Department of Health.
5. Notify the authorized investigator responsible for the area when the exposure occurred, and the Chair of the Radiation Safety Committee.
6. Carry out repeated measurements at 1 week intervals until the thyroid burden is less than 0.12 uCi of 125-I or 0.14 uCi of 131-I.
7. Evaluate the possibility of longer-term compartments containing 125-I or 131-I to ensure that appreciable exposures to these compartments do not go undetected.
C. Laboratory Monitoring Program
All areas in which radioactive materials are either used or stored in <1mCi amounts must be wipe tested weekly by the Authorized User and monthly by the RSO. Daily surveys will be conducted by the authorized user.
For Gamma Emitters and Hard Beta Emitters and quantities > 1mCi:
Daily surveys and daily wipes test will be performed by the authorized user. Surveys will be used to verify that the radiation levels in all areas accessible to personnel are such that a major portion of the body could not receive exposures exceeding:
1. Unrestricted Areas
0.2 mRem/hour
(e.g. halls, offices, non-radiation labs)
2. Controlled Areas
2.0 mRem/hour
(e.g. Type C radioisotope laboratory)
3. Restricted Radiation Areas
5.0 mRem/hour
(e.g.. Type B radioiodination laboratory)
Wipe tests are performed to detect removable surface contamination. Areas of approximately 100 cm2 are wiped with filter paper disks moistened in 70% ethanol, and subsequently evaluated by liquid scintillation counting. Samples should be counted on a multichannel program to determine the quantity and type of radioisotopes present.
All contamination in excess of 200 dpm/100 cm2 must be promptly removed. For contamination in excess of 2000 dpm, a contamination zone shall be established around the area until the contamination is removed. Contamination in excess of 20,000 dpm will initiate immediate termination of all activities in the contaminated area. The area will be immediately decontaminated by laboratory personnel under the supervision of the RSO.
All contaminated areas shall be promptly decontaminated with appropriate cleaning agents such as soap and water, D-Con, RadiacWash, or I-Bind. All contaminated materials will be processed through the corresponding routine waste streams. The contaminated area will be re-monitored by survey and/or wipe tests as appropriate to verify decontamination.
All routine or special monitoring records shall be retained in a designated monitoring notebook. Notebooks must be kept in a visible location in the laboratory for inspection by the RSO or the ODH.
No research laboratories may be monitored less frequently than on a monthly basis for record keeping purposes, and should be monitored after each experiment or use by the user as an added precaution.
Teaching laboratories used by other personnel must be monitored immediately following the conclusion of each class by the authorized investigator. Other personnel shall not be allowed to use the area until it has been demonstrated to be free of contamination.
Radioactive materials placed into long term storage in the reactor room (Room 3036 Ward Beecher) will be monitored semiannually. The method used for leak testing will be that outlined in the NRC Regulatory Guide 10.8 Appendix H. A Beckman LS6000SC Scintillation Counter will be used to determine the counts on all wipes performed on sealed sources except for alpha emitters. A Eberline ESP-2 radiation survey meter with a alpha detection probe will be used to count wipes performed on alpha emitters. All instrumentation will be calibrated using sources of known activity to determine the efficiency of the instrumentation. Any source having removable contamination above .005 microcuries will be withdrawn from use and discarded or sent back to the manufacturer for repair.
All users are responsible for monitoring their own operations. Many projects are of such a nature that monitoring instruments must be on hand at all times. The RSO maintains an inventory of calibrated survey and rate meters to be distributed to those laboratories needing such equipment. All survey meters used in the radiation safety program will be properly calibrated by the manufacturer annually.
D. Pregnant Workers
To assure the health and safety of a developing fetus, the ODH has outlined specific steps to be taken in the protection of pregnant radiation workers. Regulatory Guide 8.13 contains information which must be presented, both orally and in writing, to the pregnant worker, her supervisor, and all laboratory co-workers. In order that YSU may comply with these guidelines, all female employees must notify the Radiation Safety Officer if they become pregnant and wish their exposures to be kept below the levels outlined in Regulatory Guide 8.13. This information will be held in strict confidence, and only those individuals listed above or members of the Chemical Hygiene Committee may be notified.
E. Air and Ventilation Monitoring
The RSO shall conduct investigations of air and ventilation quality as part of the laboratory monitoring program. The purpose of the investigations is to detect defective ventilation equipment (hoods, unit ventilators, general exhaust) and evaluate concentrations of potential airborne radioactive contaminants which might pass through a workers breathing zone. Areas of particular concern are those laboratories utilizing volatile radioactive materials (i.e 3H and 125I) or operations producing dusts or aerosols.
Ventilation checks shall be performed at quarterly intervals using a digital air velocity meter as per the University’s fume hood evaluation policy. Air sampling shall be performed during all iodinations, and during any other operations deemed necessary by the RSO. Sampling shall be performed with a Sensidyne BDX 44 air sampler capable of sampling between 1.5 - 4.5 lpm. The sampling pump will be calibrated before each use with a BUCK electronic calibrated. Collection of sampling will be accomplished useing appropriate collection canisters.
F. Laboratory Audits
The RSO shall conduct periodic audits of all laboratories where radioisotopes are used or stored for the purpose of evaluating compliance with license conditions. Two main items of concern are the verification of monthly inventory reports, and the inspection of wipe test and survey records. In laboratories authorized for the use of radioisotopes but not actively using or storing radioisotopes the lab will be surveyed at the time that all radioisotopes are removed and will not be put on a survey schedule until radioisotopes are again brought back into the laboratory. Laboratories will be classified according the definition used in "The Guidelines for Maximum Activities" found in Appendix B of this manual as being either Minimum Quantity, Type C, Type B, or Type A. Irrespective of a laboratories classification it will be audited on a quarterly basis as long as radioisotopes are being stored or used in the laboratory.
V. Radioactive Waste Disposal (Back to top)
The term "radioactive waste" includes all wastes that contain, or are contaminated with, any radioactive material. This includes liquids, solids, animal carcasses, infectious materials, excreta, used scintillation counting liquids, etc. Waste and trash which are not radioactive should never be thrown in with radioactive waste, as the cost to YSU for disposing of radioactive waste is very high. All wastes must be classified and disposed according to the following categories.
A. Liquids
1. Organic based - must be collected in linear polyethylene jugs which will bear a "CAUTION RADIOACTIVE MATERIAL" These jugs will be supplied by the Radiation Safety Office. Liquid wastes are not to be stored in any other containers unless specifically approved by the RSO. All jugs containing organic radioactive waste will be stored under a working fume hood in a laboratory approved for work using radioactive materials.
2. Aqueous based - certain amounts of radioactive materials may be released into the sanitary sewer systems if the activities present are below the amounts outlined in 10 CFR 20.2003, and the chemical and physical form are shown to be readily soluble and dispersible. Because these amounts are based on the total volume of effluent released by the institution, and monthly and annual limits, all releases must be approved by the Radiation Safety Office and recorded on the individual's monthly inventory sheet. Liquid waste not released by sanitary sewer is to be collected and disposed of in the same manner as organic based liquid waste.
B. Dry Solids
Dry solid wastes must be free of all residual liquids. Solid wastes must be collected in the special waste containers supplied by the Radiation Safety Office. Needles, scalpels, and any other sharp objects must first be placed in puncture-resistant "sharps" containers to prevent injury to personnel handling bags of solid waste. All radioactive waste containers must be specifically designed for storage of radioactive waste and will bear "CAUTION RADIOACTIVE MATERIALS" labels.
C. Animal
Animal carcasses and excreta containing radioactive material must be placed in plastic bags and delivered to the reactor room where they will be frozen prior to disposal. Large animals such as dogs must be cut into smaller pieces before freezing to facilitate placement of the carcass into a standard 30 gallon drum. Individuals wishing to perform experiments using radioactive materials on live animals must submit a request, outlining all procedures to be used, to the RSO at least two months in advance. The RSO will submit plans to approve the experiment to the NRC before the work can be conducted.
D. Liquid Scintillation Vials
Currently, either plastic or glass vials can be accepted for disposal. Vials must have a capacity of 20 ml or less and may contain only the following radioisotopes in activities < .05 uCi/ml: H-3, C-14, Na-24, P-32, S-35, Ca-45, Cr-51, I-125 . There are no restrictions on the type of scintillation fluid used at this time. Used vials must be accumulated in plastic bags inside radioactive waste buckets pending their transfer to waste drums in the reactor room.
E. Short Half-Life
Short half-life isotopes (those with a half-life of less than approximately 70 days) are to be separated from long half-life isotopes, for each category listed above. Long half-life wastes are shipped for disposal, whereas short half-life wastes are decayed on site.
VI.Emergency Procedures (Back to top)
We are all human and occasionally make mistakes. There is no shame in reporting spills or contamination. There is considerable hazard in NOT REPORTING an accident involving radioactive materials. The RSO may deauthorize any individual failing to promptly report any emergencies involving radioactive materials.
A. Low Level Spill
A low level spill is one that is confined to a limited area and does not increase the radiation levels in the area beyond 2 mR/hr. It must conform to both of the following criteria.
1. The spill did not contact any part of a person's body.
2. Radiation levels 1 meter from the center of the spill do not exceed 2 mR/hr.
The authorized investigator supervising the activities in the laboratory where the spill occurred must be notified immediately. The investigator is responsible for assuring that the spilled material is collected and disposed of properly. Decontamination procedures should include the following steps.
.B. Minor Spills of Liquids and Solids
1. NOTIFY: Immediately notify all other persons in the area that a spill has occurred.
2. PREVENT THE SPREAD:
a) Liquids - Cover the spill with absorbent paper.
b) Dry material - Dampen thoroughly, taking care not to spread the contamination. Water should be used unless chemical reactions would generate an air contaminant, oil should then be used instead.
3. DECONTAMINATE: Use disposable gloves. Carefully fold the absorbent paper with the clean side out and place in a plastic bag for transfer to a radioactive waste container. Also put contaminated gloves and any other contaminated disposable material in the bag.
4. SURVEY: With an appropriate low range radiation detector survey meter. Check the area around the spill, your hands, shoes, and clothing for contamination. Wipes should be taken for weak beta contaminants.
5. REPORT: Report the incident to the Radiation Safety Officer and include survey results in the monitoring notebook. The RSO will follow up on the cleanup and will complete a Radioactive Spill Report and a Radioactive Spill Contamination Survey.
C. Major Spills of Liquids and Solids
A major hazardous spill is any spill that is not a low level spill, and DOES NOT involve contact with any part of a person's body. Procedures for major hazardous spills are as follows:
Major Hazardous Spills:
1. NOTIFY: Immediately notify all persons to vacate the room.
2. PREVENT THE SPREAD.
Confine the movement of all personnel to prevent the spread of contaminants.
Cover the spill with absorbent paper. DO NOT ATTEMPT TO CLEAN IT UP.
3. SHIELD: Shield the source if possible. This should be done only if it can be done without further contamination or a significant increase in radiation exposure.
4. CLOSE THE ROOM. Switch off all fans and hoods. Leave the room and lock the door(s) to prevent entry.
5. CALL FOR HELP. THE RADIATION SAFETY OFFICER MUST BE NOTIFIED IMMEDIATELY WHEN A MAJOR HAZARDOUS SPILL OCCURS.
6. The RSO will decontaminate personnel as per part c of this section
7. The RSO is responsible for directing the decontamination and assuring that the area is as free of contamination as reasonably achievable when decontamination procedures are completed. The authorized investigator is responsible for promptly executing all decontamination procedures deemed necessary by the RSO.
The RSO will determine the extent of the spill by monitoring the surrounding area. The contaminated area will be labeled and cordoned off to prevent inadvertent entry into the area. Only authorized personnel may enter the area until the decontamination procedures are completed.
The RSO user must complete a Radioactive Spill Report and Radioactive Contamination Report form.. An example of these forms are found in Appendix H . A meeting of the Radiation Safety Committee may be convened to determine corrective measures to assure that similar hazardous spills do not occur.
If conditions warrant, the RSO will report the incident to the Ohio Department of Health.
D Bodily Contamination (External only)
Radioactive materials in contact with body surfaces (e.g., hands) should be removed promptly using approved decontamination products such as D-Con, RadiacWash, or I-Bind. The area should be scrubbed gently and rinsed with lukewarm water.
DO NOT USE HARSH OR CAUSTIC SOAPS.
DO NOT SCRUB THE AREA WITH AN ABRASIVE TOOL (e.g., scrub brush).
AVOID PROCEDURES THAT MAY BREAK THE SKIN CAUSING POTENTIAL TRANSFER OF MATERIAL INTERNALLY.
The RSO must be notified of all accidents involving bodily contamination.
The RSO will determine whether decontamination can proceed on site or whether the individual should be transferred as a patient to the Nuclear Medicine section of Saint Elizabeth Hospital (Youngstown, Ohio).
If decontamination is carried out on site, the RSO will perform bioassays to determine when the individual is considered decontaminated. The authorized investigator will complete the Radioactive Contamination Report and submit it to the RSO.
E Bodily Contamination (Internal)
Ingestion or injection of radioactive materials must be reported to the RSO immediately. The RSO will transfer the individual as a patient to the Nuclear Medicine section of Saint Elizabeth Health Center (Youngstown, Ohio).
RADIATION EMERGENCY INFORMATION
1. Radiation Safety Office: Ext. 3700
After Work hours Call Ext.3333
2. Saint Elizabeth Health Center 746-7211
The Emergency Room at Saint Elizabeth Health Center is an appropriate treatment center for cases of radiation ingestion or injury.
Appendices (Available upon request 1-330-742-3700)
Appendix A Training and Experience of Users Form
Appendix B Guidelines for Maximum Activities
Appendix C Receipt of Radioactive Materials Form
Appendix D Radioisotope Inventory Form
Appendix E Bioassay Programs for 3H
Appendix F Bioassay Programs for 125I and 131I
Appendix G Eberline ESP-1 Specifications
Appendix H Radioactivity Spill Report Forms
Appendix I Allowable Discharge to Sewer
Monthly Reminder for Radiation Users