A faculty member, or Principle Investigator who wishes to use radioactive material regardless of quantity (exempt quantities are not excluded) or any instrument that generates ionizing radiation must follow the procedure outlined below.

1. A Statement of Training and Experience in Radioisotope Handling form must be completed.

2. An Application for a Permit to Use Radionuclides  must be completed.

 

Note: The training and experience form is only required if you are applying for the first time. However, an Application for a Permit to Use Radionuclides must be completed for requests for new radioisotopes and or protocol or project descriptions. These forms are available in section VI.

1. Institutional Radiation Safety Committee ( IRSC ) Review:

These forms must be remitted to the University Radiation Safety Officer, who will then review prior to releasing them for final review to the IRSC. This initial review is to identify deviations from Mercer University’s standard operating procedures. Once the application has been reviewed and all deviations corrected the application will be routed to the IRSC committee for review and approval. This process typically takes 3-10 business days. If an application is rejected, the applicant will be provided with the committee’s concerns and recommendations. The applicant may then revise the application and resubmit. The time necessary to process the re-application is again 3-10 business days. The applicant will be notified of the IRSC’s decision.

2.    State of Georgia Department of Natural Resources (GA DNR) Radioactive Materials Program Review:

Upon the acceptance of the proposed Statement of Training and Experience and Application for a Permit to Use Radioisotopes by the IRSC, the application documents will be forwarded to the GA DNR for approval. Once the State has approved the application, a license amendment will be issued to the University identifying these changes. The University Radiation Safety Officer will notify the Authorized User (AU ) in writing of the GA DNR’s approval.

 

 

The following categories describe the various levels of radiation training requirements and identify various positions that qualify for each level.   If it is unclear as to the level of training which you or anyone working with you should receive, please contact the school’s Radiation Safety Office ( RSO ) or University Radiation Safety Officer ( URSO ) in order to determine the appropriate level of training which is suitable for the duties of that position.

            Level 1

This level of training is provided to individuals who work in the laboratory environment.  Examples are: support staff not directly handling radioactive material, facility support staff ( e.g. custodial, maintenance, delivery, and work study students.  
            The training will include at a minimum:

                                Introduction & review of program and license requirements
        Landauer Training CD and or Radiation Safety & Common Sense
        Online training at eMercer and attain a score of 100% on the final quiz.
        ( Note this quiz is not timed can be taken numerous times.)

           Level 2

This level of training is necessary for all individuals, including Authorized Users working directly with radioactive  materials in a laboratory.

                                Nuclear Pharmacy Students

Individuals participating in a nuclear pharmacy advanced practice rotation shall be trained in radiation protection standards, fundamentals of radiation safety, and in pregnancy and a decision to declare.   In addition, these students will review program requirements, license conditions, forms and record keeping requirements at their practice sites.  

 Students performing this rotation outside of the Atlanta region may receive training and personal dosimeters by the nuclear pharmacy   where the rotation will occur, as long as training topics correlate with the training topics required by Mercer University.   Moreover, it is the responsibility of the RSO to ensure that training has been completed prior to the student commencing the rotation.  In addition, it is the RSO’s responsibility to obtain and file copies of the training.

                Level 3

             This level of training is required for all Radiation Safety Officers ( RSOs ).

Successful completion of a Radiological Safety Officers’ Training course (40 hours) and or Certification recognized by the NRC  or  Agreement States.

                Level 4

                Annual Training

Acceptable alternatives to annual training:
If an individual can provide documentation of radiation safety training that is relevant to the program and to the user’s needs; then they will be excused from completing the designated annual training course.

 

Failure to complete annual training:
If a PI or their supervisee fails to complete annual training during the mandated period, orders for radioactive material will be approved.  In addition, further action may be taken.   See section IV. Violations of Policies and Procedures.

 

Exceptions
Authorized Users who are not currently using or else do not plan to use in the upcoming calendar year, or Authorized Users who do not have any radioactive materials on hand are not required to complete annual training.   However, should research needs change, resulting in the requirement to use radioactive materials, the Authorized User will need to complete annual training prior to ordering radioactive materials.

ALL radioactive material or instrumentation which generates ionizing radiation must be entered into the FRS, even if the material is purchased by a funding or supporting company such as: the Medical Center of Central Georgia, or Merck Pharmaceuticals etc. or is a gift, or a replacement. Radioactive material is not to be purchased with any credit card, such as VISA, MC, etc. This process is necessary to ensure compliance with the conditions of the radioactive materials license, such as; individual authorization, isotope, and activity.

Below are highlights when ordering radioactive material or an instrument that generates ionizing radiation.

1. FRS screen 250: Requisition type - enter RA for radioactive material. Proceed to enter all standard information that is requested.

2. The following information must be provided for the order to be approved:

• Screen 254 ý Identify radioactive isotope and amount of activity to be ordered.

• Screen 258 ý For example, 32P (Phosphorus 32) 250 uCi or (250 microcuries).

• Screen 251 Ship To: RSO (name) /Authorized User (name)

Building where material will be used with proper shipping address; for example:

1550 College Street
School of Medicine
Macon, GA 31207

*Note make sure correct zip code is used.

• Screen 251 Requisition text: list as 111

• Call secretary name or RSO with PO #

• Provide a copy of the PO to secretary or RSO

• GA License number

• Screen 254 UPO Code

Enter “N” for no cost if the item is a gift, replacement order or if the item will be ordered through the Medical Center of Georgia or by any other means.

 

3. Once a PO# has been assigned the secretary or RSO places the order. Next, this individual proceeds to inform the RSO, Authorized User and technician when the material will be arriving, so that necessary arrangements may be made to properly receive the order.

4. When ordering radioactive material, specify the mailing address and account number. A Company will assign a specific account number to each delivery address. Including this information is critical to ensure that the material arrives at the proper location

The Physical Plant receiving personnel or designated Physical Plant employee or the courier, e.g. Fed-Ex, shall deliver all radioactive material packages directly to the school RSO or their designee.  If the Physical Plant receiving department is to provide the delivery service of the package, than the standard operating procedure for the receipt of radioactive materials at the Physical Plant must be followed.  Upon receipt of the package, the school RSO or his / her designee shall process all radioactive material packages within three hours of receipt if the package is received during normal working hours, or no later than 3 hours from the beginning or the next working day if the package is received after working hours.

 Standard Operating Procedure for Receipt of Radioactive Material Packages

1.     The RSO or their designee must complete this procedure within 3 hours.

2.    Complete a Receipt/Use Log form, assigning the new material the next chronological number as the inventory number.  Macon     inventory # will begin their numbering sequence with M followed by 4 digits starting with M0001 etc.  Atlanta inventory # will begin their numbering sequence with A0001 etc.

3.   Perform a visual check of the package to assess package integrity.  Perform a wipe and survey of the shipping container, inner container and the final container package (i.e. vial).  If contamination is within acceptable limits continue below.  If removable contamination is detected proceed to either step 5, 6 or 7 depending on the amount and location of contamination.  All necessary materials should be located on the receiving station.

4.   Label the sample and the storage unit, for example the refrigerator, with an I.D. label containing the following information:        Investigator

                                                                                                Inventory number
                                                                                                Isotope / Chemical form
                                                                                                Amount of activity
                                                                                                Date

                                Note: A Radioactive Material label must also identify the Storage areas/unit.

5.   If the outside of the package reveals removable contamination that exceeds the limits of Rule 391- 3-17-.06(15)(i); beta / gamma emitters is 220dpm/cm², the RSO shall immediately notify the final delivery carrier and the Department of Natural Resources, Radioactive Materials Program.  The RSO will store the contaminated package(s) as radioactive waste.  Note: In all instances where contamination is noted, documentation must be provided that indicates proper decontamination procedures or disposal.  It is the responsibility of the RSO to ensure that proper procedures were implemented.  . 

6.   If the vial / final container reveals removable contamination, i.e. counts greater than 3 x background, it is the responsibility of the RSO to ensure that the vial is properly decontaminated and that the process is documented.  However, not all counts above background may be removable after completing the decontamination process 3 times.   If this occurs, this must be noted and the recipient of the vial / final container must be informed of measures to reduce the possible spread of contamination that must be implemented.  Note: In all instances where contamination is noted, documentation must be provided to indicate proper decontamination procedures or disposal.  It is the responsibility of the RSO to ensure that proper procedures were implemented.  

7.   If the packing material reveals contamination, it must be treated as radioactive waste.  It is the responsibility of the RSO to ship the material as radioactive waste or complete the decay in storage process by retaining the material for 10 half-lives.   Note: It is the responsibility of the RSO to ensure that proper procedures were implemented and that process is documented.                 

8.    Make a copy of the Receipt / Use Log form, wipe test print out, and packing slip give the copy to the investigator, and retain the original in a central location, preferably a binder.

9.   The Authorized User must account for the use and distribution of the material on this log; such as: waste disposal, dry waste, liquid waste, LSV (Liquid Scintillation Vials), animal carcasses etc.

10.  The RSO or his / her designee is responsible for entering the received radioisotope data into the Health Physics Assistant database in a timely manner.

Mercer University’s Specific Limited License does NOT allow for any individuals covered by the license to transport radioactive materials themselves. Therefore, all radioactive materials requiring transfer from one location to another must be shipped via an authorized package carrier, eg. Federal -Express.

THIS PROCESS IS ONLY TO BE COMPLETED BY THE RSO OR URSO.

The Standard Operating Procedure or SOP is available from RSO.

 

 

 

1. Responsibility

All laboratories and facilities in which radioactive materials are used or stored must be monitored for contamination. This process will ensure that contamination is not spread and that radiation workers do not receive unnecessary exposure. It is the responsibility of the Authorized User (AU) to ensure that this task is accomplished and that records are maintained as required. In addition, it is the responsibility of the AU to ensure that the necessary equipment for laboratory monitoring is available to the lab personnel and provide them with training on how to use the instruments properly.

Work utilizing high-energy beta or gamma radioisotopes requires the use of a Geiger meter to perform routine surveys of laboratory areas and personnel during and after an experiment. The frequency of wipes is determined primarily, by the half-life of the radioactive material.

NOTE: If an Authorized Users has an inventory of radioactive materials, yet has not used any radioactive materials during a month, it must be noted in the log book that no radioisotopes were used during the month of   xxxx.  This document must be signed and dated, just as with all wipe test results.

2. Instrument Survey

The monitoring of work areas and personnel shall be performed after each use of radioactive materials which are capable of being detected with a Geiger Meter / Survey Meter in order to detect contamination. (This is not a wipe test!) This is a common sense practice including work areas and personnel. Completion of this survey is to be noted on the Receipt/ Use log.

1. If contamination is suspected or a spill occurs a contamination survey is to be performed after the procedure in order to document the level of contamination.
2. Document all findings on laboratory wipe / survey form.

Note: It is imperative that prior to leaving the laboratory environment that shoes and hands are monitored to avoid spreading contamination!

Geiger Meter / Survey Meter are calibrated annually. A calibration sticker is located on each counter; verify the currency of the calibration. The RSO maintains current calibrations of all radiation detection equipment.

 

3. Wipe Test

Definition: the wiping of a 100 cm2 area with filter paper, cotton tipped applicator, or other suitable material in order to detect the presence of removable contamination.

Wipe tests shall be conducted within the half-life of the radioisotope or monthly which ever comes first. A map of the floor plan identifying the locations to be wiped must be on file in the laboratory. The results must be kept on file, signed and dated with the original print out (if available) from the instrument used to count the wipes. The documentation shall include: date, individual performing wipe test, radionuclide, instrument used, serial number, calibration date, back ground results (cpm/dpm), action level (cpm/dpm), wipe location (cpm/dpm) and corrective actions taken and rewipes if needed.

1. All radioactive material users and school / campus radiation safety offices will be inspected once a year.

2. It is preferable to have the licensed Authorized User (AU) present during the inspection in    order to answer any questions regarding policy or procedure. If this is not possible, a trained technician / user of radioisotopes is the second choice. If neither are available, the RSO, (Radiation Safety Officer) for that school shall act as their representative.

3. Laboratories will be inspected utilizing the Internal Radiation Safety Laboratory Inspection Form. Radiation safety offices will be inspected utilizing the Internal Radiation Safety Office Inspection Form. Inspections will include the following: record review, isotope storage, general safety & laboratory procedures, laboratory postings, laboratories, and storage facilities. In addition, wipe tests will be conducted as part of the inspection process.

4. Inspections will either be announced or unannounced.

5. Minor deficiencies that can be corrected during the inspection will be noted as such on the inspection form as well as in the inspection report.

6. Minor deficiencies that cannot be corrected during the inspection will be noted on the inspection form as well as in the inspection report.

7. Major deficiencies would be considered acts that are in direct violation of the University’s Radioactive Material License. All major deficiencies will be noted.

8. Inspection reports will be generated utilizing the Internal Radiation Safety Laboratory/Office inspection forms.

9. Formal reports will be issued to the following by the inspecting RSO:

• RSO of the school / campus

• Investigator

• Chairman of the department and or Research Coordinator

• Institutional Radiation Safety Committee

• Associate VP for University Research and Biosafety

10. Reports will be issued to the parties listed above with in 10 days to 2 weeks of the inspection.

11. Investigators with deficiencies, minor or major, will take corrective actions and report them to the RSO who conducted the inspection in writing or via electronic mail within the specified time, typically 10 days to 2 weeks.

12. Failure to respond to the deficiencies will result in further action from the Institutional Radiation Safety Committee. See sec. IV.

13. The RSO is responsible for retaining the report and corrective actions.

 

1. Responsibility

The AU is responsible for the proper storage and security of all radioactive materials and or instruments that generate ionizing radiation. In addition, it is required that the location of all-stock solutions or instruments be identified in the Radioisotope Receipt/ Use log. This can be accomplished on the Quarterly inventory form or as a separate document in a central radiation log or notebook that remains in the laboratory.

2. Requirements

*******All radioactive materials must be kept secure at all times. This requires that all research labs, storage areas, or rooms in which any radioactive material or instruments that generate ionizing radiation are kept locked when they are not occupied. See section IV.

Stock: All stock solutions shall be kept secured unless the responsible individual is in attendance.

Waste: All waste that has been used with or is contaminated with radioactive material must be treated as radioactive waste. See Appendix A Labeling Requirements.

 

 

1. Classification

All material that is used directly with radioactive materials is considered to be waste. It is not acceptable to mix radioisotopes in the same container unless they have a similar half-life. The only time that it will be permitted to combine radioisotopes is if the protocol requires more than one radioisotope to be used in the same experiment. The form and the isotope of the waste will determine storage and disposal methods. Waste categories will be described by the half-life of the radioisotope.

Radioisotopes with a half-life > 100 days      Radioisotopes with a half-life greater than 100 days must be shipped out for disposal, with the exception of aqueous liquid waste such as ³H or ¹⁴C.

The radioisotopes that Mercer University is licensed to use which fall into this category are ¹⁰⁹Cd , ²²Na, ³H, ¹⁴C, ⁹⁰Sr, , ³⁶Cl, ⁴⁵Ca.

 

Radioisotopes with a half-life < than 100 days        Radioisotopes with a half-life less than 100 days are held in storage for decay for a period of at least 10 half lives. The radioisotopes, which fall into this category, are:³²P, ³³P, ¹²⁵I, ³⁵S, ⁵¹Cr, ²⁰³Hg, ⁶⁷Ga, ¹²³I, ¹³¹I, ¹¹¹In, ⁹⁹Mo, ⁸⁶Rb, ^99mTc, ²⁰¹Tl

***All radioactive labels or symbols must be destroyed or obliterated prior to being placed in the waste. Waste will not be accepted if this has not been successfully completed.

 

2. Storage

Note: Waste that creates undue radiation exposure or clutter or cannot be secured should not be stored in the AU’s lab. It is preferable to remove the waste frequently to provide the safest working environment for all laboratory personnel. The RSO is responsible for decay in storage or for storage of the waste until it is shipped out.

All containers used to store radioactive waste must be identified as: Caution Radioactive Material and properly labeled. See Appendix A. Storage containers must be capable of shielding radiation that is generated by the particular waste. Or the container must be shielded in an enclosure that is capable of providing the necessary barrier. In addition, distance to the radiation work area and worker should be considered to further reduce any unnecessary exposure.

Note: See Appendix A for all labeling requirements.

a. Solid Waste:

Shall be stored in lined, heavy gauge containers. Consult with RSO for appropriate container material. Due to the very high energy emitted from 32 P, all waste should be stored in plexi-glass or lucite containers. Waste must always be labeled in accordance with the labeling requirements as specified in Appendix A. The container must be kept closed at all times unless in use. Glass and /or household containers are not acceptable for waste storage.

b. Liquid Waste:

Shall be stored in a chemical resistant plastic bottle with cap on. No empty food containers or household containers are allowed! The primary container must be held in a secondary container that is capable of containing the liquid in the primary container. The container must be kept closed at all times unless in use. Glass and /or household containers are not acceptable for waste storage.

c. Liquid Scintillation Vials ( LSV ): Note only Biodegradable LS Cocktail is recommended.

LSVs must be stored separately from all other waste, in plastic pails, or trashcans with a lid. The AU may use cardboard trays for storage. However, these will not be accepted by the RSO as appropriately packaged for waste disposal.

LSVs containing< 0.05uCi / gm of medium of either ³H or ¹⁴C can be disposed of as Deregulated LSV’s. These may be stored in the same container.

LSVs containing radioisotopes other than ³H or ¹⁴C must be stored separately. LSVs containing isotopes with a half-life < 100 days will be decayed in storage by the RSO, then shipped out with the Deregulated LSVs.

d.  Sharps Containers

All “sharps” (syringes, needles, scalpel blades, etc.) that are contaminated with radioactive material shall be placed in a sharps container. Sharps must be properly identified: Caution Radioactive Material. Sharps containers must be stored behind the proper shielding if external exposure is present at the surface of the container.

*Use separate sharps containers for each radioisotope used. Do not mix radioisotopes in sharps!

e.  Animal: Carcasses, tissues, waste products, bedding, cages, and rack      
     See SOP for Animal Protocols Utilizing Radioactive Material 

Carcasses / Tissues

Must be stored in plastic bags that are capable of containing all body fluids. Grocery bags are not suitable containers. Ideally, carcasses must be stored separately by radioisotope. Carcasses should be turned over to the RSO for storage and disposal. Animal carcasses are disposed of in the same manner as solid waste.

Note: Animal carcasses containing < .05uCi of ³H , ¹²⁵I, or ¹⁴C per gram of tissue, which is averaged over the weight of the entire animal may be disposed as non radioactive.

Waste Products: Urine, Feces

Urine must be stored in a chemical resistant plastic bottle with a cap. No empty food containers or household containers are allowed! The primary container must be held in a secondary container that is capable of containing the liquid in the primary container. The container must be kept closed at all times unless in use. In addition the container should be stored to properly shield any external radiation exposure. Glass and /or household containers are not acceptable for waste storage. Store the container behind shielding if external exposure is evident.

Feces should be treated as solid waste.

Bedding / Cages / Cage Racks

All cages used to house animals that have been dosed with radioactive materials must be handled as potentially radioactive. All bedding should be surveyed prior to removal. If survey results reveal contamination, dispose of as radioactive waste. If survey results reveal no contamination, the material may be disposed of as solid waste. Wipe and survey the cage, rack and tray. If no removable contamination is found, proceed with animal care SOP for cleaning cages. If radioactive contamination is found, the cages must be decontaminated with a commercial de-con agent (e.g. Lift- Away). Rewipe and survey to document that any contamination has been removed. Once wipe test results ensure that the cage is not contaminated with radioactive materials it may then be released to the animal care staff to commence normal cleaning procedures. Document all wipes, surveys, clean up and corrective action.

f. Biohazardous waste: AU’s must receive permission prior to generating any biohazardous waste.

Previous solid and liquid waste rules apply. In addition the waste must be identified with the Biohazard symbol. The RSO will remove the waste from the AU’s lab; hold it for decay in storage, and dispose of it according to disposal procedures. Waste will be autoclaved once it has decayed.

3. Disposal Procedure

The following process is standard disposal process for radioisotopes with T ½ < 100 days. This process is to be completed by the RSO once the waste has been released to him or her.

1. Contact RSO for waste pickup once the properly labeled container is closed from further use.
2. Waste is stored in the Radioactive Materials Waste Storage facility.
3. Enter waste receipt information into the HP Assistant database.
4. Store for the calculated 10 half-life ( T ½ ) period.
5. At the end of 10 half lives, survey the waste to verify that radiation exposure is at or below ambient background levels.
6. Obliterate or remove all radiation labels, signs, and wording prior to disposal.
7. Enter pertinent information into the HP Assistant Program including date, RSO name, waste, meter used, calibration date, background, and survey results.
8. The waste is now treated as non-radioactive waste and can be disposed of in the normal waste stream.

a. Solid Waste:

T ½ < 100 days: Decay in storage follow procedure outlined above.
T ½ > 100 days: Ship out to authorized broker for disposal.

b. Liquid Waste:

T ½ < 100 days: Decay in storage follow procedure outlined above.
T ½ > 100 days: Ship out to authorized broker for disposal.

*Liquid waste containing 3H, 14C, 35S in a soluble aqueous form may be disposed of in the sewer if activity is sufficiently low - see RSO for acceptable levels.

Please refer to the SOP for Sewer Disposal of Water Soluble Aqueous Liquid

c. Liquid Scintillation Vials ( LSV )

LSVs are shipped out for disposal. See section III. . I. 2.c.

d. Sharps Containers

T ½ < 100 days: Decay in storage follows procedure outlined above to step number 6. Once completed, the sharps will be placed in the Biohazard box for incineration with other biohazard items.
T ½ > 100 days: Ship out to authorized broker for disposal. Disposal is according to their guidelines.

e. Animal

T ½ < 100 days: Decay in storage follows procedure outlined above. Once process has been completed, the carcasses are released to the Animal Care Staff and are incinerated along with other research carcasses.
T ½ > 100 days: Ship out to authorized broker for disposal. Disposal is according to their guidelines.

Note: Animal carcasses containing < .05uCi of  ³H , ¹²⁵I, or  ¹⁴C per gram of tissue, which is averaged over the weight of the entire animal may be disposed as non radioactive.

f. Biohazardous

T ½ < 100 days: Decay in storage follows procedure outlined above to step number 6. Once completed, the biohazardous material will be autoclaved and then disposed of as normal waste.

T ½ > 100 days: Ship out to authorized broker for disposal. Disposal is according to their guidelines.

 

 

 

 

Definition : the wiping of a 100 cm²  area with filter paper, cotton tipped applicator, or other suitable material in order to detect the presence of removable contamination.

Wipe tests shall be conducted within the half-life of the radioisotope or monthly which ever comes first.  A diagram identifying the zones to be wiped must be on file in laboratory.   The results must be kept on file, signed and dated with the original print out (if available) from the instrument used to process the wipe tests.  A background or blank must always be run with the samples.  The documentation shall include: date, individual performing wipe test, radionuclide, instrument used, serial number, calibration date, back ground results (cpm/dpm), action level (cpm/dpm), wipe location (cpm/dpm) and corrective actions taken and rewipes if needed.

 

Upon receipt of radioactive materials the AU will be issued a Radioisotope Receipt/ Use Log that will have all pertinent information applicable to that particular radioisotope.  One side of this form provides basic receipt information, as well as an area to record use.  It is imperative that the AU maintains complete records documenting all use in units of radioactivity and or volume.  The reverse side of the form provides the user with a method of tracking waste generated from the use of the radioactive material.  Complete use and disposition of the material must be documented in this section.  Package receipt information, use log, and waste log information is to be maintained on this form.  This form is available in section VI.
   

***ONLY THE FOLLOWING ISOTOPES ARE ALLOWED TO BE DISPOSED VIA THE SEWER AT THE DISCRETION OF THE RSO: ³H, ¹⁴C, ³⁵S

Prior to disposal of Water Soluble Radioactive Liquid Waste, the AU, technician or designee is required to complete the Sewer Disposal of Water Soluble Radioactive Liquid Waste form.  This form must be signed and approved by the RSO prior to any sewer disposal.  This form is available in section VI.

4. Quarterly Inventory report

The State of Georgia Department of Natural Resources requires that an inventory report be completed each quarter.   This report must account for all activity from the prior quarter.  In addition, the report should identify where each stock vial is located.  The RSO will provide each AU a print out of their prior quarterly inventory report according to the RSO’s records.  The AU is responsible for reviewing this document and ensuring its accuracy.  In addition, the AU is responsible for reporting all activity during the last quarter.

  An example of a quarterly inventory report and directions for completing it are available in Appendix D.

 

 

L. Information on commonly used radionuclides:  ³²P  ³⁵S  ³H  ¹⁴C  ¹²⁵I  ⁵¹Cr

Note : These are only a sample of the most commonly used radioisotopes.                                    
Refer to Handbook of Health Physics and Radiological Health, Third Addition, edited by Bernard Shleien, Lester Slaback, Jr., and Brian Kent Birky Copyright 1998

1. Attire

While working with radioactive materials, appropriate clothing optimizes personnel safety. Knee length laboratory coats, gloves, and monitoring badges are mandatory. Eye protection is encouraged. Therefore the following items are not permitted: open toed shoes, sandals, high-heeled shoes, or shoes that do not have non-skid soles, and shorts.

For additional information and guidance please refer to the Science Laboratory Operations manual.

Personal dosimeters

It is mandatory that dosimeters (film badges, TLD badges, etc.) be worn at all times when working with radioactive material or working in an area where radioactive material is used. Badges should be worn at the chest or waist level depending on how you handle radioactive material and on the outer most layer of clothing. Placement of the badge is important and should be determined prior to commencing work with radioactive materials. Consult with RSO for appropriate placement for your situation. Badges / rings are to be stored in a designated area when it is not being worn.

*Personal dosimeters must only be worn when working with radioactive materials or ionizing radiation or when you are in a signed restricted area!

 

 

2.     Personal Protective Equipment ( PPE )

Laboratory coats                                                                                             

Laboratory coats or other protective clothing must be worn while working in the research laboratory where radioactive material is used or stored. Knee length coats are preferred and must be buttoned.

Gloves                                                                                                                  

Disposable gloves are to be worn while working with unsealed sources radioactive material. Gloves may be doubled in order to reduce the risk of contamination. The practice of double gloving is strongly recommended when using millicurie amounts of radioactivity.

Gloves are to be removed prior to entering a non-restrictive area.

Eye/Face protection                                                                                                  

Safety eyeglasses, goggles, or face shield is recommended as needed while working with radioactive materials.

 

3.     Identification of work areas and equipment

Laboratories:

All laboratories or rooms in which work with radioactive materials occurs or rooms which house equipment or instruments which generate ionizing radiation must be clearly identified at the entrance with a sign noting: CAUTION RADIOACTIVE MATERIAL or CAUTION HIGH RADIATION AREA. Consult with the RSO for appropriate signage. Access to restricted areas is for authorized personnel only. These areas must be secured or locked when authorized personnel are not present.

Work surfaces:

Work areas and equipment which are used for work with radioactive materials must be clearly identified with radioactive material tape, or “Caution, Radioactive Material” tags. Yellow and magenta colored tape may also be used to identify work areas and equipment. All work surfaces should be lined with absorbent poly-backed disposable paper. The poly-backed side should be down with paper side up.

Waste containers

Radioactive waste containers must be placed in an area that is clearly outlined or identified as radioactive material. In addition, adsorbent material or poly-backed paper must be placed under all storage or waste containers to contain any contamination, which may be accidentally released.                                                                                                      

  ****Radioactive waste containers must also be identified as containing radioactive material.

Equipment:

Any piece of equipment, whether it be a refrigerator or a pencil, which is used while working with radioactive materials, must be identified with radioactive material tape, yellow or magenta colored tape, or labels that identify it as “Caution, Radioactive Material”. In addition, these materials should never be found outside of a “caution, radioactive material” area. All items that are used with or while working with radioactive material should be regarded as contaminated.

4.     Time, Distance and Shielding are three factors affecting external exposure.

Time                                                                                                                         

The longer you are exposed to radioactive materials or radiation, the greater your exposure will be. When working with radioactive materials it is extremely important to use time effectively and efficiently.

Distance                                                                                                                  

The greater the distance between a person and a source will result in less exposure. Use remote handling devices such as tongs or hemostats to increase the distance and reduce the exposure.

The Inverse Square Law: double the distance from a source, reduces the exposure by ¼.

 

Shielding                                                                                                          

Shielding is the easiest and most practical method of reducing exposure. Use shielding whenever possible; such as bench top shields constructed of either plexi-glass, Lucite, or lead lined; storage boxes for stock solutions; storage boxes for pipette tips or other materials which have high activity; waste (liquid and solid) should also be stored in an appropriate shielded container. Appropriate shielding is specific to the type of radiation. One half-value layer (HVL) will reduce the exposure by 50 %. 10 HVL approximately reduces the exposure by a factor of 1000 (1/1000 or 0.001). Consult the RSO for appropriate shielding and thickness.

 

5.      Laboratory Rules

• Optimize Time, Distance and Shielding to reduce personnel exposure.
  

 

• Before the procedure is actually performed with radioactive material, perform a “dry run” or practice run prior to performing the experiment with radioactive materials. This will optimize the Time, Distance and Shielding approach to reducing exposure.

 

• Absolutely no food or drink allowed in the laboratory.
  

 

• Application of cosmetics is prohibited in the laboratory.
  

 

• Never pipette by mouth.
  

 

• Wear a buttoned laboratory coat or other acceptable protective clothing at all times while working in the laboratory.
  

 

• Wear a film badge or other issued dosimeter while working in the research laboratory. This badge must be placed at chest or waist level.
  

 

• Wear a ring badge while working with high-energy beta or gamma emitters.
  

 

• Wear disposable gloves, preferably double gloves, while working with radioactive materials. Gloves must be removed when leaving the work area.
  

 

• Wear protective eyewear or face shield when appropriate while working with radioactive material.
  

 

• Always monitor hands, feet, and clothing prior to leaving restricted areas. If contamination is found, decontamination must be performed immediately.
  

 

• Line work area with poly-backed absorbent material.
  

 

• Identify work area with acceptable radioactive material labels or tape.
  

 

• When possible and practical shielding should be utilized. In addition, remote-handling devices should be used. This will reduce personnel exposure.
  

 

• Contain and confine all radioactive material, solutions, and or waste-solid or liquid, in covered containers that are labeled as radioactive material, identify radioisotope, activity, date and investigator, and in-house number.
  

 

• Transport radioactive materials using a cart and appropriate shielding and or secondary containers.

 

• Perform contamination and laboratory surveys as directed by the project protocol.

 

 

 

N. Decommissioning of Instruments / Equipment / Laboratory

It is mandatory that any instrument, equipment or laboratory space that has been used for work with radioactive materials be decommissioned prior to releasing it as non-radioactive.

Decommissioning requires that the instrument, equipment or area be thoroughly cleaned of all potential contamination. To achieve this task, the item or area must first be wipe tested, next the item or area must be cleaned with a de-con agent if results show evidence of contamination, and finally, if contamination was present the item or area must be cleaned until contamination is no longer present. This information must be retained for documentation. In addition, if contamination still exists the area must continue to be cleaned with a de-con agent until levels are below the sited action levels. If this can not be achieved, notify the RSO.

All decommissioning information must be retained in the radiation log with surveys, signed and dated.

 

Any woman who becomes pregnant while working in a restricted radiation area has the option of declaring her pregnancy in writing to the RSO. This formal declaration of pregnancy sets radiation limits for the embryo / fetus of the pregnant woman. At this time, the RSO will request that the pregnant woman declare this pregnancy in writing, with an estimated date of conception. This information is required in order to determine the fetal monitoring period, i.e. the time of declaration to birth. The declared pregnant woman will be issued a fetal badge that is to be worn at waist level while working in an area in which radioactive materials are used. In addition, the RSO can provide additional information concerning radiation and pregnancy.

If a worker is planning a pregnancy and has concerns regarding potential biological effects on the embryo / fetus, they may wish to discuss these concerns with the RSO in advance. The RSO can provide them with additional training and information addressing radiation workers and pregnancy.

A declared pregnant woman can not exceed exposure limits of 500 mRem for the entire gestation period. In addition, their exposure should not exceed 50 mRem /month.

 

Working with volatile or dispersible 125I and 131I requires compliance with the guidelines set forth in the NRC Regulatory guide 8.20 Applications of Bioassay for125I and131I be followed.

• Any individual handling 1 mCi of unsealed, volatile, radioactive iodine or sufficiently close to the process should participate in the thyroid bioassay program.
• Baseline Thyroid Bioassay: Prior to commencing work with material.
• Routine Thyroid Bioassay: Bioassay should be performed no sooner than 6 hours after the exposure, but within 10 days from the exposure.

It is the responsibility of the Authorized User to ensure that all individuals who meet these qualifications participate in the bioassay program. It is the responsibility of the Radiation Safety Officer to conduct the baseline and routine thyroid bioassays and retain all results.

Radiolabeling procedures must be performed in the Radiolabeling Room located on the first floor in the East Wing of the School of Medicine. See RSO to obtain a copy of the standard operating procedure for the use of this facility.

 

Q.  Retirement or Extended Leave: Responsibilities of the Authorized User (AU)

Prior to retirement or extended leave, the AU will notify the RSO and make proper arrangements for disposal of remaining radioactivity.  With assistance from the RSO, the laboratory will be decommissioned.  That is the laboratory must be certified free of radioactive contamination by wipe test and all radiation signage removed.  Laboratory records pertaining to use of radioactivity will be removed and kept by the RSO for the required time period (3 years or longer as deemed necessary by the RSO).  When an AU takes an extended leave, such as a sabbatical, and if use of radioactivity is to be continued in the lab, then the AU shall designate a responsible person approved by the RSO.  If continued use of radioactivity is not anticipated during leave, then the lab shall be decommissioned as with retirement.

 

R.  Record Retention

This policy was developed in accordance to the Georgia Rules and Regulations for Radioactive Materials, Chapter 391-3-17, revised 6/25/02.   Mercer University will adopt the requirements for the retention times of various records.

Occupational Dose Records

All records pertaining to occupational doses; prior occupational dose records, individual occupational dose records, records from accidents or emergencies,  doses to members of the public ( these are records used to demonstrate compliance with limits) must be retained until the department terminates the license and at that time the university either will make provisions to retain the records or transfer them to the state.

Radiation Protection Program Records

Retain the following records for 3 years*:

·        Records of audits and program reviews

·        Records of surveys

·        Records of survey instrument calibrations

·        Records of leak tests of sealed sources

* Note that the time begins from the date the record was made.

Retain the following records until the department terminates the license and at that time the university either will make provisions to retain the records or transfer them to the state:

·        Records of the provisions of the program must be retained until the department terminates the license and at that time the university either will make provisions to retain the records or transfer them to the state.

·        Records that may have been used to determine an individual’s dose to external, or internal sources of radiation

·        Records used to calculate or show the results of air sampling, surveys, bioassays, or the release of radioactive effluents into the environment

·        Records for all waste disposals

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