Ehs Procedures Handbook

University of Virginia

Office of Environmental Health & Safety

Radiation Safety

Radiation Safety Notebook

TABLE OF CONTENTS

§1OEHS phone/address Listings

§2 Authorization to Use Radioactive Material

2.1AuthorizationCategories

2.2Training Requirements

2.3Application Forms

§3Procurement, Receipt and Inventory of Radioactive Materials

3.1OrderingRadioactive Material

3.2Procedure for Opening Radioactive Packages

3.3Radionuclide InformationSheet

3.4Laboratory RadionuclideInventory Recordkeeping

§4Radioactive Waste

4.1Management and Disposal Procedures

4.2Radioactive Waste Ticket Instructions

§5Radiation Surveys

5.1Survey Procedures

5.2Portable Survey Instruments

5.3Fixed Counting Systems

5.4Laboratory Radiation Survey Report Cover Sheet

5.5Survey Instrument Use Guidance

§6Adding/Removing Rooms from your Authorization

6.1Procedure for Commissioning Rooms

6.2Procedure for Decommissioning Rooms

§7Policy for Use of Radioactive Materials inthe Vivarium

§8Personnel Monitoring

8.1Radiation DosimeterUse Guidelines

8.2Radio-bioassay Guidelines

§9Radiation Emergency Procedures

§10Security Requirements for Radioactive Material

§11OEHS Correspondence

§1 Telephone and e-mail listings of Radiation Safety Staff

For a current listing of OEHS Staff Members and Contact Information, please visit the OEHS website:

Office of Environmental Health & Safety ...... 982-4911

1

§2 Authorization to Use Radioactive Material

§2.1AUTHORIZATION CATEGORIES

Authorized Radionuclides and Limits

See your PI Radioactive Material Project Data Summary Sheet for authorized radionuclides, possession limits, approved rooms and personnel. Amendments to your authorization must be approved in writing by the Office of Environmental Health & Safety (OEHS). You may use the amendment form found on the “Forms” webpage or send an email request to the Radiation Safety Officer. You will receive an updated Radioactive Material Project Data Summary Sheet once the amendment is approved.

Authorized Rooms

All radioactive material use rooms must be pre-approved by our office. These rooms must be posted with a Hazard Communication sign bearing the "Caution: Radioactive Materials" warning, a Virginia Department of Health "Notice to Employees" and emergency response phone instructions. Only the PI may request room additions, deletions, or exemptions. You may use the amendment form found on the “Forms” webpage or send an email request to the Radiation Safety Officer.

Authorized Personnel

All independent radioactive material users must complete training and apply to EHS to become authorized for use (see Section 2.2 - Training). Individuals approved under a specific PI must notify EHS if they transfer to another lab/PI.

There are three levels of authorization at the University of Virginia:

1. Principal Investigator for Possession & Use of Radioactive Material – this is usually (but not always), the lab director or faculty member responsible for the research in that lab. This person may order and possess radioactive material, train and supervise other approved personnel working with radioactive material and supervise unauthorized personnel in temporary work situations.
2. Authorized User for administration of radioactive material to humans – must meet specific training and experience requirements specified in the regulations and apply to be listed as an AU on the UVA radioactive materials license.

2.Qualified User - may supervise and train other approved personnel to work with radioactive material, and, if EHS is provided written approval from the PI, they may order radioactive material for the PI.

3.General User - may work independently with radioactive material, but may not supervise or train other personnel and may not order radioactive material.

4. Temporary User - may temporarily use radioactive material only under direct supervision of a PI or Qualified User. A temporary user has not received authorization from the Radiation Safety Committee to work with radioactive materials.

§2.2 TRAINING REQUIREMENTS FOR RADIOACTIVE MATERIAL USERS

It is the responsibility of the Principal Investigator or Authorized User to ensure that all personnel who work with radioactive material under their authorization have completed the required UVA radiation safety training.

You must complete radiation safety training:

• before assuming duties working with radioactive materials or radiation-producing equipment
• during annual refresher training and
• whenever there is a significant change in duties, regulations, terms of the license or type of radioactive material or therapy device used.

Individuals who have not completed training are not allowed to work independently with radioactive material. They may, however, work under the direct supervision of their Principal Investigator, Qualified User or Authorized Usertemporarily until they have completed their training requirements.

Individuals with no previous experience working with radioactive material:

These individuals must satisfactorily complete the following:

• Radiation Safety Training Course (RSTC)
• Radiation Safety Training Course Examination
• An application for the category of user desired

The RSTC is an online course available through the EHS website. The Radiation Safety Guide Lecture is included in this course.

Individuals with previous experience:

Completion of the Radiation Safety Training Course may be waived at the sole discretion of the RSO, or the Alternate RSO, based on the following:

The individual supplies documentation of training from the institution at which he or she was authorized to use radioactive material. A letter from that institution’s RSO or Radiation Protection Manager (RPM) must be provided that contains the following information:

A statement attesting that the individual attended and completed the Radiation Safety Training Course offered by that facility.

• A copy, or description, of the course syllabus
• Duration of the course in hours

2.2

• Date of the course
• The RSO, or RPM, signature
• This letter must be on letterhead and dated

The RSO is not bound to accept previous training even upon satisfactory evidence that a previous course was completed. Reasons for not waiving attendance at the UVA RSTC may be that the earlier training was not of sufficient scope or was over 7 years in the past.

If documentation of previous training is accepted and completion of the UVA RSTC is waived, the individual will be required to satisfactorily complete the following:

• Radiation Safety Guide Lecture training course
• An application for the category of user type desired

The Radiation Safety Guide Lecture Training Course and all other radiation safety training courses are available on-line at the EHS website:

Other individuals who may require training:

Ancillary personnel such as housekeeping staff, lab support personnel, etc. may require radiation safety training under certain conditions. Individuals working with blood bank irradiators or other special sources will require specialized training. Our office provides customized training for these groups of individuals. Please contact us for further information if you think you fall into this category.

Non-Occupational Exposure (General Public)

Non-occupationally exposed workers (e.g. physical plant, housekeeping, secretarial staff) should be reminded to follow basic radiation safety practices. Any visitor to radioactive material use areas must be escorted by an individual who is properly trained.

Annual Retraining Requirement for All Radiation Workers

In addition to the initial training requirements, there is an annual retraining requirement. Anyone who uses radioactive material while working at UVA must complete annual retraining. If a user fails to complete the required retraining, they may lose the authorization to work with radioactive material. Re-authorization can only be obtained after completion of retraining. Re-training is normally provided on line throughthe OEHS website. A live lecture can be provided if a request is made to our office.

§2.3 APPLICATION FORMS

A copy of the most current applications for PI, Qualified user, General user and amendment forms to add radionuclides may be found on the OEHS website through the following link:

The PI may initiate commissioning of new rooms or decommissioning of existing rooms by calling Environmental Health & Safety at 982-4911, sending a fax to 982-4921 with a brief explanation of room change requirements, or sending e-mail to the RSO with similar explanation.

Any change in areas/rooms of radioactive material use or equipment requires notification to our office.

Use of radioactive materials in human investigation (research) must be approved by the Human Investigation Involving Radiation Exposure (HIRE) Subcommittee of the Radiation Safety Committee. For additional information, contact the RSO at 982-4911.

Radiation Safety NotebookRev. 12/2017

§3.0Procurement, Receipt and Inventory of Radioactive Materials

3.1 ORDERING RADIOACTIVE MATERIAL

The University’s radioactive material license requires us to maintain a current inventory of all material possessed under the license. Only individuals approved by the RSC may procure radioactive material. Consequently, all radioactive material orders must be approved by OEHS. For instructions on ordering radioactive material at the University of Virginia, please use the following link:

If you are required to have someone in your Department approve the requisition, you need to establish who that person is and alert them that the order needs approval prior to 12 Noon of the day that you want the material to be ordered.

If you require assistance with placing an order, please contact one of our radioactive material buyers at .

§3.2 PROCEDURE FOR OPENING RADIOACTIVE MATERIAL PACKAGES

All packages containing radioactive material should be opened immediately to determine that the correct material and quantity has been received. Use the following procedure and open the package in a hood or other radioactive material work area with a prepared surface to contain any spills should they occur during package opening.

1. Put on a lab coat and gloves to prevent personal contamination.
2. Visually inspect the package for signs of damage (e.g. wet or crushed). If damage is noted, stop the procedure and notify the Radiation Safety Officer (RSO) or designee.
3. Inspect the packing slip to confirm that the correct material was received.
4. Carefully open outer packaging and locate inner container of radioactive material.
5. Open the inner package and verify that the contents agree with the packing slip.
6. Check the integrity of the final source container. Look for broken seals or vials, loss of liquid, condensation, or discoloration of the packing material.
7. If anything is other than expected, stop and notify the RSO (or designee).
8. If you suspect that the inner vial or container may be leaking or contaminated, wipe the external surface of the container and assay the wipe sample to determine if there is any removable radioactivity.
9. Survey the packing material and the empty package for contamination with an appropriate radiation detection survey instrument before discarding. See Section 3.3 for appropriate instrumentation.

a. If contaminated, treat this material as radioactive waste.

b. If not contaminated, remove or obliterate the radiation labels before discarding in the regular trash.

10.Record receipt of material in your radioactive material inventory log. These logs should be maintained in your laboratory's Radiation Safety Notebook.

§3.3 RADIONUCLIDE INFORMATION SHEET

1 Curie = 2.22 x 1012 dis/min1 Curie = 3.7 x 1010 dis/sec

1 Millicurie = 2.22 x 109 dis/min1 Millicurie = 3.7 x 107 dis/sec

1 Microcurie = 2.22 x 106 dis/min1 Microcurie = 3.7 x 104 dis/sec

§3.4 LABORATORY RADIONUCLIDE INVENTORY RECORDKEEPING

Radioactive material must be under the control and surveillance of the user at all times. Maintenance of inventory allows the user to determine that material has not been lost or stolen.

A separate inventory sheet must be maintained for each radionuclide.

Write the receipt date on the stock vial to assist with inventory reconciliation.

Radionuclide inventory sheets must be maintained in the laboratory and available for review by OEHS and State inspectors. DO NOT dispose of any of these records. They may be needed for future inspections.

Method for documenting the laboratory’s inventory:

Use a separate inventory log sheet for each stock vial. When a stock vial is ready for disposal, close out the inventory log for that vial and file in your notebook. This type of inventory system has been designed to allow users to accurately track radioactive material and provides documentation of control to inspectors. You will be provided with an inventory sheet with each radioactive material package delivered by our office.

Remember to make all entries in ink (black ink recommended for durability). Entries must include the complete date, including the year. Inventory activity must be reported in units of µCi, mCi or Becquerels (Bq). Units of volume or concentration are not permitted.

Use of any other inventory system or form must be approved by the RSO prior to use. All inventory log sheets must be maintained in your laboratory’s "Radiation Safety Notebook" with the exception of current in-use inventory sheets. For ease of use, these may be posted in a visible location, accessible to us during lab surveys.

Inventory logs must be kept up-to-date. Failure to maintain a centralized inventory system can jeopardize your authorization to use radioactive material at UVa.

Intra-university or laboratory transfers of radioactive material are allowed. However, only the PI or an EHS-approved Qualified User designated to order radioactive material may approve its transfer and receipt. A transfer is considered the same as ordering from a commercial vendor. After all approvals have been made (verbal approval is acceptable), both laboratories' inventory logs must be amended to reflect the change in inventory due to the transfer. Care should be exercised so as not to transfer radionuclides for which the recipient is not authorized. It is the responsibility of the person authorizing the transfer to ensure that the transfer is performed properly.

3.4

The inventory sheet is also used to record waste activity removed from the lab’s inventory. A waste disposal section is provided on the inventory log sheet. Decay of the waste activity is not necessary.

It is important to maintain inventory records as accurately as possible. Proper maintenance of these records is essential for ensuring all radioactive material is accounted for.

REMEMBER…….

Radiation Safety NotebookRev. 12/2017

§4.0RADIOACTIVE WASTE

§4.1RADIOACTIVE WASTE MANAGEMENT & DISPOSAL PROCEDURES

OEHS provides all radioactive waste containers, radioactive waste pickup services

and consultation. To request a radioactive waste pickup, fax your waste ticket(s) to

982-4921. If you are unable to fax us this information, you may still call EHS at 982-4911. The waste ticket must include the following information:

Name of caller

PI name and PI number

Today’s date and lab phone number

Waste location: building and room

Waste container size, radionuclide(s) and activity in mCi

Type of container to be replaced or emptied

Indicate the presence of contamination

Note any problems with the waste.

Radioactive waste will be picked up on scheduled weekdays. Please call EHS at 2-4911 for current schedule). If waste is not picked up during those times, please call EHS again. Free (unbound) Iodine-125, high-activity waste and biological waste will be picked up on an expedited schedule. To expedite pickup, please call EHS before generating these types of wastes.

Please do not stockpile any radioactive waste. Call waste in regularly even if the container(s) are not full. Regular removal of waste reduces radiation exposure to lab occupants and reduces the likelihood that waste content knowledge will be lost.

 Radioactive waste must be segregated by radionuclide.

Each radionuclide has a unique half-life and environmental release limit. Improper co-mingling of radionuclides can delay the disposal of waste and may necessitate shipment of the material to a radioactive waste repository at a significantly greater cost to the University. Please contact EHS if you find it necessary to co-mingle radionuclides. It may be done only if it does not impact the University's waste processing and reduction program.

The University of Virginia’s license requires waste containingisotopes with half-lives greater than 120 days (e.g. Co-57, Co-58, Na-22, Cl-36, Zn-65), to be shipped offsite for disposal. EHS will advise your lab on methods to minimize waste containing long-lived isotopes.

§4.1

 Radioactive waste must be segregated by physical form.

Dry Solids: This category includes such items as contaminated paper, plastic, glass, and metal. No standing liquids or blood-contaminated items are allowed in our solid waste boxes. A small volume of liquid (< 50 ml) is permissible in the dry solid waste container.

Do not place Sharps in solid waste boxes. Sharps must be placed in approved and radioactively labeled sharps containers (provided by OEHS) prior to disposal. The closed sharps containers may then be placed in the solid waste boxes.

Waste Scintillation Vials: All scintillation vials must be placed in trays and treated as a separate waste item with its own waste ticket. Vials containing radionuclides with half-lives greater than120 days, i.e. Carbon-14 (14C) or Tritium (3H), must be segregated from other radionuclidesand placed back in the empty cardboard tray they were received in. Carbon-14 and H-3 vials may be placed in the same tray. Clearly label each tray with the radionuclide name. Label the tray with radioactive warning tape. Place the waste vials in the tray in an up-right position and ensure that they are securely capped to minimize spills. Be sure to keep the cardboard tray in secondary containment (e.g. in a tray) in case of spills.

Organic Solvent-Based Scintillation Vials: Organic solvent-based scintillation fluors must be packaged separately. Since these vials may leak, do not store this waste for long periods of time.

Complete a waste ticket in the same manner you would for other forms of radioactive waste and be sure to check the “liquid” check-box and indicate you have scintillation vials to be picked up. If your lab does not purchase scintillation vials in cardboard trays, or you do not have empty trays available for your waste, please contact our office and they will be provided to you.

Bulk Liquids: Any liquid whose volume is greater than 50 ml is defined as a bulk liquid.

•Use a separate waste container for each nuclide.