Radiation Safety Manual

Introduction
Responsibilities
Authorization to Use Ionizing Radiation
Dosimetry
Training Requirements
Acquisition & Transfer
Monitoring, Labeling & Handling Procedures
Radioactive Waste Disposal
Radiation Producing Machines
Emergency Procedures

 

This manual describes policies and procedures that govern the use of ionizing radiation by CSUN employees and students.

I.  Introduction

1.0  Background

The State of California Department of Public Health (CDPH) has the responsibility imposed by the California Radiation Control Regulations, Title 17 of the California Code of Regulations (17 CCR), for evaluating and approving or disapproving each proposed use of radioactive materials subject to its specific licensure.

Normally, the CDPH issues a separate license for each proposed use of radioactive materials.  However, for the administrative convenience of both the CDPH and California State University, Northridge (CSUN), a "Broad Scope Authorization" license has been granted to CSUN.  The CDPH has delegated the authority and responsibility to CSUN for "licensing" individual users of radioactive material.  This responsibility is discharged by the Radiation Safety Officer (RSO) in conjunction with the Radiation Safety Committee (RSC).

Radiation producing machines are not subject to the “Broad Scope Authorization” and are registered with CDPH.

1.1  Purpose

This Radiation Safety Manual has been established to inform users of ionizing radiation at CSUN of the policies that govern its use and of the procedures required to obtain approvals.  The purpose of the radiation safety program is to ensure that work with sources of ionizing radiation is conducted in such a manner as to protect health, minimize risk to life and property, and keep radiation exposures as low as reasonably achievable (ALARA).  Fulfillment of this purpose should be to the greatest practicable extent consistent with the educational and research goals of the University.

1.2  Scope

Except as provided in the following paragraph, the provisions contained in this Manual apply to all persons using ionizing radiation at CSUN.

Any persons, products, concentrations, and quantities of radioactive material are exempt from the requirements of this Manual as specified in 17 CCR 30180.  The State of California's regulations will govern CSUN's statements in applications or letters, unless the statements are more restrictive than the regulations.

Each Authorized User (AU) will be assigned a copy of the Radiation Safety Manual when the Ionizing Radiation Use Authorization (IRUA) is approved.  The Authorized User must make this official copy available as a reference to persons engaged in the project. 

II.  Responsibilities

2.0  Radiation Safety Committee: (RSC)

• Basis:  The State of California requires a radiation safety program and a committee to direct the program as a condition of the radioactive materials license issued to the University.  The President of the University is ultimately responsible for the efficacy of the program.
• Membership:  The Radiation Safety Committee shall consist of at least five members, including representatives from administration, the radiation safety office and faculty.  Members shall be knowledgeable and experienced in relevant radioactive materials use and in radiation safety.  Members of the Committee shall be appointed by the President (or designee) and shall serve at the pleasure of the President.
• Responsibilities:  The Committee shall evaluate and maintain surveillance over all uses of radioactive material and other sources of ionizing radiation at the University.  The Committee shall be the organization at the University that ensures that the use of ionizing radiation meets or exceeds the safety requirements contained in the CSUN Radioactive Materials License and the provisions of State and Federal regulations.  This responsibility includes the authority to suspend or revoke permission to use ionizing radiation at the University.
• Authority:  The Committee’s authority is derived from the obligation of the President to ensure a safe environment for students, staff and visitors in conformance with State and Federal radiation control regulations.
• Meetings:  The Chair of the Committee shall convene the Committee as often as is necessary to consider all issues relevant to radiation safety, but not less than twice each year. A quorum (simple majority) must be present for a meeting to be official. No quorum shall exist in the absence of the Radiation Safety Officer (RSO) or the RSO’s designee.  An action item shall pass or fail by the majority of those present (each member shall have one vote). The RSO (or RSO’s designee) shall record the minutes of the meetings, and distribute these minutes to all members 

2.1  Environmental Health & Safety: (EH&S)

EH&S is responsible for surveillance of all sources of ionizing radiation and providing consultation and radiation safety services in conformance with policies and standards set forth in this Manual, governmental regulations, and license conditions.

• Director, Environmental Health & Safety:  The Director of Environmental Health & Safety is responsible for the review of campus performance regarding radiation safety and serves as a member of the RSC.
• Radiation Safety Officer (RSO):  The Radiation Safety Officer (RSO) is responsible for all aspects of radiation safety on campus.  The RSO is responsible for advising the CSUN President on all matters related to radiation protection, for reviewing and approving all proposed uses of ionizing radiation, and for advising and guiding Environmental Health and Safety in carrying out the campus radiation safety program. 

2.2  Manager Purchasing and Contract Administration

The Manager of Purchasing and Contract Administration is responsible for the acquisition, through established procedures, of all sources of ionizing radiation.  The Manager is assisted by the RSO in determining that anyone requisitioning a source of ionizing radiation is authorized for its possession and use. 

2.3  Deans, Department Chairs and Administrative Officers

Deans, Department Chairs, and Administrative Officers are responsible for review and approval of proposed uses of ionizing radiation within their jurisdiction.  Such approval signifies that the Department will provide the resources necessary to control hazards and remediate any contamination or other damage caused by the use of sources of ionizing radiation.  They will support the policies and procedures required to comply with pertinent CSUN and governmental standards and regulations.

2.4  Authorized User

The Authorized User (AU) is personally responsible for compliance with all CSUN and governmental regulations as they pertain to his/her authorized use of radioactive materials or radiation-producing machines.  Specific responsibilities include, but are not limited to:

• Ensuring that all work with ionizing radiation is approved and listed on the Ionizing Radiation Use Authorization (IRUA).
• Ensuring that only personnel that have been properly instructed and authorized for work involving sources of ionizing radiation perform the work.
• Ensuring that all personnel under his/her supervision have received adequate instruction in proper procedures for control of radiation hazards and assuring that radiation exposures are reduced to levels as low as reasonably achievable (ALARA).  This instruction must include, but not be limited to, the following:
• Reading and understanding the Ionizing Radiation Use Authorization (IRUA).
• Reading and understanding the CSUN Radiation Safety Manual.
• Reading and understanding the State of California Department of Public Health
• Form RH 2364, "Notice to Employees." (Appendix D)
• Reading and understanding other training materials as specified by the RSO or RSC.
• Maintaining records to document the following:
• An accurate inventory of all radioactive materials and/or radiation producing machines in possession, including receipt, usage, transfer, and disposal records.
• Monitoring of laboratory and other workplaces to check for contamination levels and radiation levels.
• Annual refresher training
• Annual calibration of radiation survey instruments used for monitoring.
• Proper disposal of waste radioactive materials.
• Any transfers of radioisotopes to and from campus.
• Calibration and maintenance records for radiation producing machines.
• Exposure histories or other dosimetry/bioassay records, if applicable.
• Compliance with this Manual and applicable regulations.
• Making the records listed above available for inspection at reasonable times by Environmental Health & Safety and authorized government agencies.
• Notifying personnel under his/her supervision of any radiation exposure record data.
• Posting any required hazard warning signs, labels on radioisotope containers, storage locations, and use areas.
• Providing materials and equipment required in the Ionizing Radiation Use Authorization (IRUA) and enforcing the use of these items (including protective clothing, personnel dosimeters, survey instruments, etc.) by personnel involved in work under his/her IRUA.
• Conducting routine surveys of authorized workplaces to assure compliance with the Ionizing Radiation Use Authorization and general safety requirements.
• Contacting the Radiation Safety Officer (RSO) regarding any proposed changes in the use of ionizing radiation, addition or deletion of authorized users, addition or deletion of locations of use or storage of radioactive materials, or proposed changes in facilities.
• Providing the necessary staff required to comply with CSUN policies and procedures and governmental regulations, such as proper management of wastes, contamination surveys, and record keeping.
• Maintaining the following documents available for inspection by the RSO and authorized government agencies:
• Ionizing Radiation Use Authorization and all supporting documentation.
• Statements of Training & Experience for Authorized User's staff listed on the IRUA.
• CSUN Radiation Safety Manual
• Form RH 2364 "Notice to Employees" (must be conspicuously posted).

• Notifying the RSO in cases of personnel contamination, accidents, or other unusual events that lead to contamination of work areas, personnel, or equipment or releases of radioactive materials or radiation beyond the confines of the authorized work areas.
• Enforcing the use, by individuals under his/her supervision, of personnel dosimetry, survey meters, protective clothing and equipment, and other equipment specified in this Manual or by the RSO.
• Disposal of all radioactive wastes using procedures approved by Environmental Health & Safety.  (See Section 8).
• Enforcing submission of required bioassay samples or keeping appointments for required bioassay.

2.5  Authorized User's Staff

  An Authorized User's staff, for the purposes of this Manual, consists of all persons authorized to use ionizing radiation under an Authorized User's IRUA.  An Authorized User's staff has the following responsibilities:

• Maintaining all occupational radiation exposures as low as reasonably achievable (ALARA).
• Informing the Radiation Safety Officer of any unsafe or questionable conditions known to exist.
• Using protective equipment and dosimetry, as specified on the Ionizing Radiation Use Authorization. 

III.  Authorization to Use Ionizing Radiation

3.0  CSUN'S License

Currently, CSUN holds a Broad Scope Authorization license (#0319-19) issued by the State of California, Department of Public Health (CDPH).  Copies are available for inspection at the CSUN Environmental Health & Safety Department, Corporation Yard room 218, Northridge, California.  This license describes the possession limits for each radioisotope, the locations for use, and provides for internal campus authorization procedures.

The Radiation Safety Officer must approve any requests for amendments to the campus radioactive materials license, subject to Radiation Safety Committee review.

Machines capable of producing ionizing radiation are not currently subject to licensing by federal or state regulatory agencies.  However, the State of California requires registration of each operable radiation machine, except those exempted in 17 CCR.  The Environmental Health & Safety department registers these machines biennially. 

3.1  Obtaining Authorization to Use Ionizing Radiation

• Persons Eligible to Apply for Ionizing Radiation Use Authorization (IRUA):

Anyone appointed to the CSUN faculty is eligible to become an Authorized User (AU).  This includes appointments as active or emeritus professors, associate professors, assistant professors, instructors, adjunct faculty, and lecturers, whether serving under visiting, acting, research, clinical, or affiliate appointment, and whether part time or full time.  Other persons who are not faculty members but have primary responsibility for a radiation program may be considered for Authorized User status.  Normally this will happen only when a faculty member clearly cannot have responsibility for the radiation program.

An Authorized User must have at least twenty (20) hours of training or practical experience in the characteristics of ionizing radiation, radiation dose quantities, radiation detection instrumentation, and the biological hazards of exposure to radiation.

• IRUA Application Procedure: 

A written proposal must be submitted to the Radiation Safety Officer for review by the Radiation Safety Committee to receive, possess, or use sources of ionizing radiation at CSUN, whether procured by purchase, loan, gift, or previous ownership.  All proposals must include the following:

• Completed "Application for Ionizing Radiation Use Authorization" (Form 101). 
• A "Statement of Training and Experience" (Form 201) for all persons who will use ionizing radiation as part of the IRUA.
• Diagrams of each room where radioactive materials will be stored or used-indicate on diagram all locations where radioactive materials (RAM) will be stored or used.

Note:  All forms can be found in Appendix B

Send completed application package to RSO at mail code 8284

The Radiation Safety Officer  (RSO) is available for consultation and assistance in developing the radiation safety aspects of any project and for help in completing the Application forms. 

Authorized Users who have active IRUA's and wish to add a new protocol, need only to submit a completed "Application for Ionizing Radiation Use Authorization" (Form 101)

• IRUA Review and Approval Process

The applicant may submit a preliminary copy of the application to the Radiation Safety Officer for unofficial review and suggestion.  The Radiation Safety Officer can review the application, visit the facility, and make recommendations as necessary to ensure adequacy of the Application.

The RSO may also issue an interim approval for routine applications until formal review and approval by the RSC.  Upon formal approval by the Radiation Safety Committee, the Radiation Safety Officer will issue an "Ionizing Radiation Use Authorization" (IRUA). 

3.2  Radiation Safety Review:

• Hazard Assessment of Projects:  Each project that uses ionizing radiation will be reviewed for hazard potential.  Upon receipt of the completed Application for IRUA, the Radiation Safety Officer conducts a detailed review of the radiation safety aspects of the proposed project.  This review usually includes an interview with the applicant and a visit to the proposed use location(s). All applications must be reviewed and approved by a quorum of the RSC, including the RSO.
• Audits of IRUAs:  The RSO or a designated alternate will make periodic audits of IRUAs to ensure compliance with regulations and good radiation protection practice.  Within one year of issuance of an IRUA and annually thereafter, the EH&S Office will audit the total program of the Authorized User.  This audit may include:
• Inspection of the laboratories and work areas
• Personal interview with the Authorized User
• Safety evaluation regarding activities authorized on the IRUA
• Evaluation of compliance by the Authorized User with campus and governmental regulations and special requirements of the IRUA
• Review of records for accuracy and completeness

 A report of the audit findings and requirements (if any) for corrective action will be sent to the Authorized User and a copy placed in the Authorized User's IRUA file.   Copies will also be sent to the AU's department   Chair and College Dean.  These reports are reviewed by the Radiation Safety Committee and can influence future approvals of an Authorized User's requests for IRUA. 

3.3  Period Issuance for IRUAs:

• Research Projects:  IRUAs will be issued for a nominal period of one (1) year.  For bookkeeping purposes, not more than six months may be added to the above time period, to allow the expiration date to fit into a schedule established for administrative efficiency.  The Radiation Safety Officer or the Radiation Safety Committee may establish a shorter period in any case deemed appropriate or necessary for radiation control purposes.

• Academic Courses:  IRUAs for academic courses will usually be issued for one academic year.  However, at the option of the Radiation Safety Officer, IRUAs for academic courses that will be repeated or continued under the same Authorized User in subsequent semesters may be issued for two to four semesters, as appropriate.

3.4  Administrative Actions onIRUAs:

• Renewal and amendment of existing IRUAs:

The Radiation Safety Committee, including the Radiation Safety Officer, must approve renewals and amendments of original IRUAs.

• Termination/Suspension of an IRUA:

Upon termination or suspension of an IRUA, all radioactive material must be accounted for.  Unused amounts must be transferred to another active IRUA, placed in approved radiation storage, or disposed of as radioactive waste.

• Termination by Authorized User:  When an Authorized User foresees termination of his/her use of ionizing radiation, the Radiation Safety Officer must be notified promptly.  Prior to termination of the IRUA, all radioisotopes listed on the IRUA must be accounted for, and an acceptable plan for removing the radioisotopes must be determined and approved by the Radiation Safety Officer.  Unused amounts of radioisotopes must be transferred to another active IRUA or to EH&S for storage or disposal.
• Termination/Suspension by Radiation Safety Committee:  The Committee has the duty to take action against an Authorized User whose actions are a threat to human health or the environment or a serious violation of safety regulations. The Radiation Safety Committee may terminate or suspend the use of ionizing radiation at any time under certain conditions (see section 2.0 (c)).

To reinstate an IRUA following suspension or revocation requires approval by a quorum of the Radiation Safety Committee.

• Internal Enforcement Actions:

In order to ensure compliance with Ionizing Radiation Use Authorization (IRUA) conditions, the Radiation Safety Office annually conducts audits of all Authorized Users (AU's).  Audit results, including regulatory or license condition violations, are conveyed to the Authorized Users, Department Chair, Dean of College and The Radiation Safety Committee.  Audit findings that may result in regulatory violations will be addressed as follows:

• Serious Findings:   Any finding of a present or imminent threat to human health or the environment will be corrected immediately.  The Radiation Safety Committee may suspend or terminate the use of ionizing radiation at any time under these conditions.
• Minor Findings:  "Minor Findings" are findings that are not imminent hazards but nonetheless may result in a regulatory violation if not corrected.  Examples include failure to provide refresher training, or to conduct required wipe testing.
• 1^st Minor Finding:  Audit results (violations) are provided to parties specified above and the user is informed, in writing, of any areas that need improvement.
• Repeat (2^nd) Minor Finding:  A repeat violation is a violation of the same regulation or license condition, found at the time of the next scheduled audit. Audit results will be provided, as before, to the parties specified above but in addition the repeat violation will elicit a written warning that the authorized users license will be suspended if that violation is not corrected.  The Authorized User will be re inspected within 30 days.
• Repeat (3^rd) Minor Finding:  If the next audit or inspection reveals continuing non-compliance on the same issue(s) the Authorized User's radiation license will be automatically suspended.  All work with ionizing radiation will be prohibited until, 1) the authorized user provides a written compliance plan to the Radiation Safety Committee, 2) The Radiation Safety Committee approves the compliance plan.
• Repeat (4^th) Minor Finding:  If the next audit or inspection reveals continuing non-compliance, the Authorized User’s license will be terminated.  All work with ionizing radiation will be prohibited.  The RSO will take possession of the user’s radioactive materials inventory and any radiation producing machines will be locked out.  Reauthorization for use of ionizing radiation may not be approved; in any case reauthorization would require a new application, the approval of the Radiation Safety Committee, and presumably more restrictive and cumbersome license conditions.  The Department Chair, and appropriate College Dean, as always, will be informed regarding the process. 

IV.   Dosimetry

4.0  ALARA Policy:

To achieve radiation exposures as low as reasonably achievable (ALARA), CSUN maintains an ALARA program.  This program includes elements in training, audits, dosimetry and license review.  CSUN has established a campus limit of ten percent (10%) of allowable limits prescribed by 10 CFR Sections 20.1201 - 1206.  Furthermore, exposures to the public will be maintained as low as reasonably achievable, and below levels specified in 10 CFR 20.1301-20.1302.  The RSO will investigate, and mitigate when possible, any occupational exposure in excess of 100 mrem / quarter.  All users are encouraged to mitigate any exposure by reasonably achievable means.

4.1  External Dosimetry: 

The AU is required to ensure that appropriate dosimetry is used by all persons listed on their IRUA who use ionizing radiation in a manner that presents a reasonable likelihood of the following doses:

• Adults:  Likely to receive, in one year from sources external to the body, a dose in excess of 10% of the occupational dose limit (10 CFR 20.1201a) 
• Minors and declared pregnant women:  Likely to receive, in one year from sources external to the body, a dose in excess of any of the applicable limits (10 CFR 20.1207 or 20.1208).

Dosimetry records are legally presumptive evidence of personnel exposures.  Therefore, it is imperative to use dosimeters only as prescribed.  The RSO or RSC may require the use of dosimetry in situations that would not ordinarily justify their use when it appears to be in the best interests of CSUN.

It is the responsibility of each individual anticipating use of ionizing radiation to provide the RSO with a copy of his occupational exposure record for all radiation exposures received before coming to CSUN.

Personnel working with radioisotopes may be required to wear protective garments to prevent contamination of their clothing and body.  The minimum fulfillment of this requirement is the standard laboratory coat.  Subject to the discretion of the RSO and RSC, additional protective equipment and garments, appropriate to the hazard potential, will be prescribed in the IRUA.

• Exchange and Replacement of Dosimeters:  The dates printed on the dosimeter indicate the monitoring period.  If the date on the dosimeter is older than the exchange date, immediately contact the CSUN Radiation Safety Officer before continuing work with ionizing radiation.  Persons who lose a dosimeter must, immediately contact the CSUN Radiation Safety Officer before continuing work with ionizing radiation. 
• Precautions:        
• DO store dosimeters away from radiation sources when not in use.
• DO protect dosimeters against contamination (e.g., wear finger rings under gloves, etc.).
• DO NOT use any dosimeter without an appropriate badge holder.
• DO NOT wear a dosimeter without the printed information facing away from the part of the body where the highest dose is expected.
• DO NOT wear a CSUN-issued dosimeter at any facility other than CSUN unless authorized to do so.
• DO NOT wear a CSUN-issued dosimeter to any location where you may be exposed to X-Rays that are not part of your IRUA (e.g. dentist or doctor office, airport security screening).
• DO NOT intentionally expose your dosimeter to radiation just to "test" it.
• DO NOT dispose of a dosimeter.  If a dosimeter is no longer needed, return it to the CSUN Radiation Safety Officer.
• DO NOT puncture or cut a dosimeter with staples, scissors, tacks, etc.
• DO NOT expose the dosimeter to hazardous chemicals, liquids, or excessive heat.
• DO NOT loan a dosimeter to anyone.  DO NOT borrow anyone else's badge.

If you have any doubts whether your dosimeter has been lost, damaged, or compromised in any way, immediately contact the CSUN Radiation Safety Officer before continuing work with ionizing radiation.

4.2  Internal Radiation Dosimetry  

All uses of radioactive materials will be evaluated for potential internal exposure as part of the IRUA review and renewal process.  Isotope possession limits, work practices and/or engineering controls may be implemented or modified to prevent the need for bioassay.  Bioassay will be available in the event of an emergency release.

• Radioactivity Levels for Participation in Bioassay:  Individuals will be monitored for intake of radioactive material when the following doses or exposures are likely:
• Adults:  likely to receive, in one year an intake in excess of 10% of the applicable Annual Limit on Intake (ALI)  (10 CFR 20 appendix B) 
• Minors and declared pregnant women:  likely to receive, in one year, a committed effective dose equivalent in excess of 0.05 rem.

Radioactive materials users handling unsealed I-125 or H-3 will participate in a bioassay program when the activities handled exceed the following (based on USNRC regulatory guides 8.20 and 8.32):

Note: For declared pregnant workers these values are divided by 10.

Radioactivity Levels for Iodine -125 Requiring Bioassay

Process Area	Volatile	Bound
Open room or bench top	1 mCi	10 mCi
Fume Hood	10 mCi	10 mCi

Radioactivity Levels for H-3 Requiring Bioassay

Process Area	Condition A	Condition B	Condition C
Open room or bench top	0.1 Ci	100 Ci	10 mCi/kg
Fume Hood	1 Ci	1000 Ci	100 mCi/kg

        Condition A - HTO and tritiated organics including DNA precursors

        Condition B - Tritium gas in sealed process vessels

        Condition C - HTO mixed with more than 10 kg of inert H20 or other material 

        Campus use of H-3 and I-125 will be compared to these values on a case-by-case basis during license review. 

• Internal dose calculation:  Internal dose calculations will be performed when necessary, using the results of the bioassays.  Estimates of dose from internal exposure will be added to the individual's total effective dose equivalent (TEDE) in accordance with applicable regulations. 

• Bioassay threshold calculation:  For isotopes other than H-3 and I-125, a radioactivity reference level is calculated for determining the necessity for participation in bioassay.  This reference level is the minimum activity used by an individual which is likely to result in intake in excess of the standards, thus requiring participation in a bioassay program.

The reference level is calculated for each isotope based on the Annual Limit on Intake (ALI), and modified by factors that credit users for safety controls and account for procedures that increase the potential for intake.  A safety factor is included to provide for a margin of safety and account for uncertainty.  The calculation is conducted as follows:

        Q = ALI(inh)(0.1)(C)(R)/(50)(10^-6)(F)

        Where:

        Q = the minimum quantity of radioactivity used by an individual which requires participation in bioassay.

        ALI(inh) = the lower of SALI or NALI for inhalation = factor to account for 10% of ALI

        C = containment factor for open bench top work

                        1 for fume hoods

                        10 for glove boxes

        R = release fraction

                        1 for volatile and gaseous materials

                        10 for nonvolatile powders

                        100 for nonvolatile liquids

                        1000 for nonvolatile solids

        50 = number of working weeks in a year

        1X10 (-6)  = probability factor for intake (NUREG-1400)

        F = safety factor, usually given a value of 10 or 100

• Emergency Bioassay:  Emergency bioassay will be conducted in the event of an accident in which a worker has likely received an intake in excess of 10% of the ALI or a minor or declared pregnant woman is likely to receive a committed effective dose equivalent in excess of 0.05 rem.  Emergency bioassays will be conducted using off Campus resources.

Procedures: The exposed individual will be decontaminated as close as practicable to the release site to prevent the spread of contamination. The RSO will supervise this decontamination with the assistance of the Campus Chemical Emergency Response Team.

Resources: Samples will be taken at an on-site Student Health Center or alternatively at Northridge Hospital Medical Center.  Sample counting and a dose assessment will be done using off-site resources.  Possible resources are listed below:

• UCLA radiation safety program and associated consulting health physicists
• Mutual aid within the California State University system,
• National laboratories consulting services

• Precautions:  No person shall eat, drink, smoke, apply cosmetics, or otherwise make possible the ingestion of radioactive materials in areas authorized for use of unsealed radioactive materials.  Upon completing their work with radioactive materials, persons should thoroughly wash their hands before eating, drinking, smoking, etc.
• Reduce the possibility of work surface contamination with good laboratory work practices and frequent monitoring of hands and work areas.
• Reduce the possibility of exposure to air borne radioactivity by:
• Using a fume hood whenever possible
• Minimizing the volatility of solutions
• Sealing containers whenever possible
• Not conducting activities which tend to aerosolize radionuclides (e.g. grinding, pouring powders, heating or disturbing liquids mechanically)

4.3  Investigations of Overexposure

The RSO will review all dosimetry results and is responsible for notification to the CDPH in cases of known or suspected exposure above the legally permitted exposure limits.  All exposures in excess of 100 mrem / quarter will be investigated by the RSO.  When an exposure reaches or exceeds legal limits, depending on the extent of the overexposure, personnel may be required to avoid future work with ionizing radiation for an extended time. 

4.4  Pregnant Workers  

All female employees who work with ionizing radiation will be given a copy of the U.S. Nuclear Regulatory Commission’s Regulatory Guide 8.13 – “Instructions Concerning Prenatal Radiation Exposure” (Appendix E).  In the case of a “declared pregnancy”, exposures will be maintained according to 10CFR 20.1208. 

4.5  Records

Federal and state regulations (10 CFR and 17 CCR) specify the radiation dosimetry records, reports, and notifications required for institutions using radioactive materials.  The Radiation Safety Officer is responsible for maintaining a permanent record of the occupational radiation exposures for all persons who participate in the dosimetry program at CSUN.

• Requests for Exposure Reports:  Individuals who have participated in the dosimetry program at CSUN may request a copy of their occupational radiation exposure history, in writing, from:

Radiation Safety Officer, EH&S
California State University, Northridge
18111 Nordhoff Street
Northridge, CA 91330-8284
(818) 677-2401

In the written request, please specify: the dates when you participated in the dosimetry program, whom you worked for/with, your social security number, your birth date, and the address to which the report is to be forwarded. Occupational exposure records are confidential, so none may be forwarded without a written request. 

V.  Training Requirements

5.0  Requirement for TraIning

Authorized Users are responsible for ensuring that all individuals who may be exposed to ionizing radiation by an activity listed on their IRUA be instructed in the precautions to minimize exposure and prevent the spread of radioactive contamination.  The Radiation Safety Officer will assist with this training as required.

5.1  Formal Training of New Users 

The Authorized User is responsible for ensuring all individuals listed on their IRUA receive adequate radiation safety training.  The RSO will conduct general introductory training for new users at the AU's request.  The Authorized User must conduct training that is specific to projects.  The topics covered by these types of training are:

• Training to be provided by RSO:

• Radiation and its interactions with matter.
• Definitions of unit dose, quantity, etc., and methods of calculating and measuring radiation levels for an appropriate variety of sources.
• Biological effects of chronic and acute doses of radiation.
• Personnel dosimetry and bioassay procedures.
• Standards set by regulations and license conditions.

• Training to be provided by Authorized User: 

• Methods to control surface contamination.
• Contamination survey procedures
• Proper use of protective clothing and equipment.
• Emergency procedures.
• Exposure minimization fundamentals (ALARA)
• Operating and emergency procedures specific to the Authorized User's staff.
• Proper maintenance of records of receipt, use, transfer, and disposal.

After training, all new users are required to complete a test and certification of training.  Students using ionizing radiation as part of a classroom IRUA may satisfy the training requirements by their classroom training. 

5.2  Periodic Refresher Training

The Authorized User shall present periodic refresher training at least annually.  Training should include the following:

• Changes in regulations and IRUA conditions affecting the Authorized User's operations.
• Changes in operating procedures.
• Emergency procedures.
• Control and measurement methods specific to laboratory
• Maintenance of records of training, dosimetry, contamination surveys, and records of receipt, use, transfer and disposal of radioactive materials.

This training must be documented and maintained for inspection by the RSO - use Form 207 "Refresher Training Record".  EH&S can provide guidelines for the design of refresher training programs. 

5.3  Special Training Requirements for Animal User 

Authorized Users are responsible for ensuring that animal caretakers and custodians are aware of potential hazards and are adequately trained in necessary precautions when radioactive materials are administered to live animals. 

5.4  Training for Academic Activities (Non-Occupational)

 Authorized Users are responsible for ensuring that all individuals who may be exposed to ionizing radiation as part of an academic activity receive radiation safety training.  This training can be part of the class curriculum or conducted separately and shall cover (as applicable) the topics listed in 5.1. 

5.5  Documentation of Training

All radiation-safety related training or education that students or employees receive, whether from EH&S or within the laboratory, must be properly documented and maintained on file for review by EH&S and state regulatory agencies. 

VI.  Acquisition & Transfer

6.0  Acquisition

 A valid IRUA must exist to receive, possess, or use sources of ionizing radiation at CSUN, regardless of the funding source.  Also, any acquisition of radioactive materials must be within the limits established in the IRUA.

6.1  Procedure for Ordering Radioactive Materials

When ordering radioactive materials (RAM), the Authorized User must ensure that the purchase is within the limits of their Ionizing Radiation Use Authorization (IRUA), and that the package is inspected immediately on arrival by EH&S.  The procedures for ordering RAM are:

• Ensure that the material(s) you are purchasing does not exceed the limits specified in your Ionizing Radiation Use Authorization (IRUA).  Make sure that existing inventory is considered when determining if additional RAM may be purchased.
• Notify the RSO PRIOR to ordering the material (email is acceptable).  Provide the following information:
• Isotope and activity
• RAM vendor
• Anticipated arrival date

• When placing the RAM order, the "Ship to" address must be:

California State University Northridge
Central Receiving (RADIOACTIVE MATERIAL)
18111 Nordhoff St.
Northridge, CA 91330-8293

•  Once the RAM has been ordered and a shipping date has been determined, contact the EH&S Office (ext. 2401) with the order/reference number so that we can coordinate the delivery with Central Receiving.

Inspection and monitoring of all RAM packages will take place within 3 hours of receipt (or within 3 hours of the beginning of the next work day for late arrivals).  Once the package has been inspected, it will be delivered to the Authorized User by EH&S.
Upon receipt, all incoming radioactive material shipments will be inspected by EH&S for:

• Conformity with the approved requisition specifications
• Damage/contamination of the contents or shipping containers
• Conformity with applicable regulations (CDPH, USDOT, etc.)
• Other safety considerations

If the shipment passes inspection, it is released to the Authorized User, and the RSO adds the material received to the AU’s radioactive material inventory. 

6.2  Custody

The Authorized User is continuously responsible for the custody of any source of ionizing radiation possessed, used, or stored under his/her IRUA.  The AU is also responsible for the proper storage, labeling, use, and disposal of the material or machines, and for maintaining proper records. 

6.3  Inventory Procedures 

Records of the receipts, transfers, and disposal of authorized radioactive materials or radiation producing machines must be maintained at all times.  It is the responsibility of the Authorized User to keep the inventory up-to-date. 

6.4  Transfer  

All transfers of radioactive materials must have specific prior approval of the RSO.

• From off-campus facility:  In addition to receiving approval from the RSO, the AU must present a copy of the receiving institution’s radioactive materials license (if applicable) to the CSUN RSO before the transfer occurs.

• To off-campus facility:  All transfers of radioactive materials to off-campus facilities must have specific prior approval of the CSUN Radiation Safety Officer and the receiving institution’s RSO.  When a short half-lived radioactive material is to be transferred, prior approval of the CSUN RSO may be accomplished by a verbal notification, followed within ten (10) calendar days by a written transfer record to the CSUN RSO.  The CSUN Authorized User will be responsible for ensuring the prior notification to the CSUN RSO.  Packaging, monitoring, and labeling of radioactive materials must be approved by the CSUN RSO.

• On-campus transfers:  On-campus transfers of radioactive material must have prior approval of the RSO.  Use Form 103 "Radioactive Material Transfer From" to accomplish this approval.  

 VII.   Monitoring, Labeling & Handling Procedures

7.0  Contamination Surveys  

While the majority of radiation control programs at CSUN rely on correct experimental design, the problem of contamination is most easily handled when the personnel directly involved with the project routinely conduct appropriate contamination monitoring surveys.  Routine laboratory surveys are required in research and teaching laboratories to detect excessive radiation levels and/or contamination in order to alert laboratory personnel to potential hazards. 

• Survey Frequency:  When using unsealed radioactive materials, contamination surveys will be conducted according to the frequencies listed below.  Note:  These are minimum requirements; more frequent surveys (where appropriate) are encouraged.

Radiation Type	Examples	Survey Frequency
Beta (<200 KeV)	H-3, C-14, S-35	Weekly
Beta (>200 KeV)	P-32, P-33	Daily
Gamma	I-125, I-131	Daily

        Contamination surveys do not need to be performed during periods when no radioactive materials are used.

• Survey Method:  Contamination surveys can be conducted using a variety of methods.  The two most common methods are "area" and "wipe" surveys.

• Area survey:  Measures both fixed and removable contamination and are performed with a portable radiation survey meter.
• Wipe survey:  Measures only removable contamination and is performed by wiping a surface with a small "wipe" and then counting the wipe with an appropriate radiation counting device.

It is important to select and use a contamination detection instrument that is appropriate for the type of radioactive material being used.  Following are the recommended contamination survey instrument for the types of radiation typically used at CSUN:    

Radiation Type	Examples	Detector
Alpha              Cf-252	Alpha counter	Wipe test - LSC
Beta <200 KeV              H-3	C-14, S-35	Wipe test - LSC
Beta >200 KeV              P-32	P-33	Pancake GM, Wipe test - LSC
Gamma	I-125, I-131	Pancake GM, NaI Scintillation, Wipe test – LSC

 

• Conducting the Survey:  Note:  when conducting contamination surveys, it is important to avoid contaminating yourself and/or the survey equipment.

• Area Surveys:  At CSUN, the most common type of survey instrument that will be used is a pancake GM detector.  Perform the survey by holding the detector close to, but not touching the surface being surveyed and then move it in a pattern that will allow the active area of the probe to traverse the entire surface being surveyed. 
• Wipe Surveys:  Wipe 100 cm² of the surface to be checked for contamination with an appropriate absorbent material.  The wipe sample is then counted with the appropriate counter/detector system to determine activity.

• Recording Survey Results:  The Authorized User must maintain permanent records of all contamination surveys, including negative results.  The records will include:
• Location and date of survey.
• Type of instrument used.
• Name or initials of person conducting survey
• Simple drawing of area surveyed - can reference laboratory diagram that is part of IRUA application.
• Survey results keyed to locations on the area drawing.
• If contamination is found, the results of retesting after decontamination.

Form 105 (Appendix B), can be used for recording contamination survey results.

• Determining Compliance:  Survey area must be decontaminated if the following contamination limits are exceeded:

• H-3:        2,200 dpm/100 cm²
• All other isotopes:                220 dpm/100 cm²

Area must be resurveyed after decontamination and results of the resurvey documented. 

7.1  Leak Testing of Sealed Sources

 As specified in 17 CCR section 30275, sealed sources containing radioactive material above the following quantities shall be tested for external contamination/leakage by the EH&S Office:

• Beta and Gamma emitting sources:  100 microcuries
• Alpha and/or neutron emitting sources:  10 microcuries

Note:  H-3, Kr-85, source material, and materials in gaseous form are exempt from leak testing.

Permanent records of the results of these tests will be maintained by the RSO. 

7.2  Responsibilities  

Each Authorized User must have access to an instrument that is capable of detecting radiation levels that will allow an adequate hazard assessment.  No Authorized User may use or store sources of radiation in such a manner as to cause a radiation exposure above the limits specified in 10 CFR 20.  

If contamination or unusually high radiation fields develop in uncontrolled areas at any time, it is the responsibility of the Authorized User to notify the RSO immediately after the AU becomes aware of the situation.  Notify the RSO in advance if a procedure is anticipated to lead to contamination or any other radiation hazard.

The RSO shall conduct periodic surveys of all areas in which significant radiation may be present and institute or recommend appropriate corrective measures in cases where contamination or other sources of potential hazards are detected.

Within one year after authorization is granted and annually thereafter, the EH&S Office will audit the ionizing radiation use program for each Authorized User.  The review normally includes a field investigation by the RSO, a review of radiation and contamination monitoring surveys during the past year, with the findings submitted to the Radiation Safety Committee.

7.3  Storage and Labeling

Radioactive materials must be stored in a manner that prevents unauthorized removal from the place of storage.

Each Authorized User must conduct and maintain semi-annual physical inventories to account for sealed sources under their control.  Records of the inventories must be maintained and kept available for inspection and must include the quantities and kinds of radioactive materials, location of sealed sources and the date of inventory.

All entrances to radioactive material use or storage rooms must be posted with a sign or label that reads:

"Caution - Radioactive Material." 

Radioactive materials may not be transferred to, or used in an unposted area, except in the following limited case:  Posting is not required for temporary use (not to exceed four (4) hours) in areas in which there is a trained individual in constant attendance to prevent exposure of any individual to radiation or radioactive material.

All containers holding radioactive materials during transport, for storage, or during processing and use, must be conspicuously labeled "Caution - Radioactive Material."  Also, the label must specify the identity of the isotope, the activity, and the date of assay. 

State of California Form RH2364, "Notice to Employees," must be permanently and conspicuously posted whenever radioisotopes are in use.  Additional copies can be obtained from the RSO.

 7.4  Handling

Every person who uses ionizing radiation is responsible for taking precautions to ensure that radiation exposures are as low as reasonably achievable (ALARA).  The IRUA will prescribe additional specific precautions and conditions.  The following is excerpted from the Department of Public Health Broad Scope License requirements document:

• Control of External Exposure: 

Exposure time, distance from the source, and shielding control the external radiation exposure from a given radiation source.  

Increasing the distance from the source is frequently the most effective and economical means to reduce radiation exposure from gamma rays and other highly penetrating radiations.  The radiation field varies inversely with the square of the distance.  For this reason, always use tongs or other long-handled tools for manipulating radionuclide preparations emitting significant levels of radiation.  Radioactive materials should never be picked up with the fingers.  Low-level sources can be handled with short forceps that provide a large reduction in exposure when compared with direct skin contact.

Decreasing the time of exposure decreases the radiation dose proportionately.  It is important to include "dry runs" with non-radioactive material for critical steps in planning of all work that may involve substantial radiation exposure.  Carry out new procedures in a dry run with non-radioactive materials before using the radioactive material.

Shielding the source of radiation will be necessary when the maximum distance and minimum time do not ensure a significantly low exposure to operating personnel.  A material with a high atomic number (Z) is most effective in absorbing most types of radiation.

High Z materials should not be used to shield materials that emit beta particles (e.g. P-32).  Beta rays produce penetrating radiation called bremsstrahlung.  The intensity of the bremsstrahlung varies directly with the square of the energy of the beta radiation and the average atomic number (Z) of the shielding material.  Therefore, use low atomic number materials such as plexiglass for shielding beta radiation wherever possible.  When working with energetic beta emitters, avoid exposing hands above opened containers where the dose rate can be on the order of rads per minute for commonly used quantities of beta emitters such as P-32.

• Control of Internal Exposure: 

Time, distance, and shielding are obviously not available for protection when the source of radiation is internally incorporated into the body through inhalation, ingestion or injection.  Preventing physical contact with unsealed sources of radioactive material most easily controls internal exposure.  Always use significant quantities of unsealed radioactive material inside properly designed exhaust-ventilated enclosures.

In a well-designed low or moderate level laboratory, wear protective clothing consisting of laboratory coats and rubber or plastic gloves when working with radioactive material.

• Work Rules:  The following rules of good radiation protection practice should be carefully observed by all radiation workers to prevent unnecessary radiation exposure and to minimize contamination.

• DO wear lab coats and impermeable gloves when working with radioactive material.
• DO work with radioactive material in an exhaust-ventilated enclosure.
• DO store and transport containers of radioactive solutions on trays that will hold the contents of the primary container in the event of breakage.
• DO line trays and working surfaces with absorbent paper.
• DO keep all radioactive materials in sealed containers.
• DO clearly label all containers of radioactive material and post all radiation and storage areas with the standard radiation warning symbol.  Labels on containers should bear: the legend "Caution - Radioactive Materials," the nuclide and quantity, and the date of assay.  Placards for posting of radiation and storage areas should include, "Caution - Radiation Area" or "Caution - Radioactive Materials."
• DO conduct work with radioactive material by written radiation safety and operating procedures.
• DO carry out new procedures in a dry run with non-radioactive materials before using the radioactive material.
• DO monitor regularly around work areas after each procedure where there is any possibility of contamination.  Keep records of such surveys.
• DO clean up spills promptly.
• DO NOT eat, drink, smoke, or apply cosmetics in radioactive materials use or storage areas.
• DO NOT pipette by mouth.

VIII.  Radioactive Waste Disposal

8.0  General Requirements

All radioactive waste must be transferred to the RSO for disposal.  No radioactive materials can be discharged into the campus sewer system or into the air without specific prior approval by the campus RSO to assure compliance with applicable government regulations.

All wastes must be segregated by isotope and physical form.  Different physical forms include (but are not limited to):

• Solid waste (e.g. gloves, paper or glassware)
• Organic liquid waste
• Aqueous liquid waste
• Scintillation vials
• Animal or bio hazardous waste

Each container of radioactive waste must be labeled with the following:

• Radioisotope(s)
• Total activity of each isotope and the reference date for the activity
• Authorized User
• "Radioactive" label (can use yellow "Radioactive" tape)
• Other potential chemical or physical hazards

A CSUN Radioactive Waste label (Form 107) can be used for this purpose. 

8.1  Requirement by Waste Type

 In addition to the general requirements listed in 8.0, the following waste specific requirements also apply:

• Mixed Waste:  Mixed waste is waste that falls into the regulatory definition of both "hazardous waste" and "radioactive waste".  Because of the conflicting regulatory requirements that apply, and the substantial economic burden incurred with mixed wastes, the generation of mixed wastes is strongly discouraged.  Activities that generate mixed waste will be reviewed by the RSO as part of the IRUA review/renewal process. 

• Solid Waste:  All dry solid radioactive waste must be accumulated in plastic lined containers that are suitable for the type of solid waste being stored.  When determining the suitability of a particular container, consider factors such as the strength and integrity of the container, and the shielding provided by the container.  EH&S can assist with container selection.
• All containers must be labeled as described in section 8.0.
• All sharps (e.g. needles, syringes or broken glass) must be placed in a container that has been designed for accumulating sharps.
• No liquids, animal wastes, hazardous wastes, or active pathological agents are permitted in solid waste containers.  Biohazards must be deactivated before disposal.

• Organic Liquid Waste:  Organic liquid radioactive waste must be collected in plastic bottles (no larger than one gallon each) with screw-tight caps.  Secondary containment shall be provided for containers while in storage (e.g. plastic tub).
• All containers must be labeled as described in section 8.0.
• Disposal of liquid radioactive waste through the sewer system is prohibited unless specifically approved by the RSO.

• Aqueous Waste:  Aqueous radioactive waste must be collected in plastic bottles (no larger than one gallon each) with screw-tight caps.  The pH of aqueous wastes must be maintained between 5 and 9 (iodine compounds between 7 and 9).
• All containers must be labeled as described in section 8.0.
• Disposal of liquid radioactive waste through the sewer system is prohibited unless specifically approved by the RSO.

• Liquid Scintillation Vials:  LSC vials may be accumulated in vial racks/boxes and then transferred to EH&S for disposal.  Label the entire rack with the label described in 8.0.

• Sharps Waste:  All sharps must be placed in a sharps container that must have some means of visual inspection.  The sharps container must be thick enough to prevent any possibility of puncture.  Sharps include needles, syringes, pipette tips, broken glass etc.

• Animal Carcasses, Human Tissue, or other Bio-hazardous Waste:  Methods for containing and storing bio-hazardous waste will vary depending upon the volume and form of the waste.  In general these types of wastes must be sealed, frozen and labeled as described in section 8.0.  Projects likely to produce large quantities of waste or involve unusual contamination potentials will be reviewed by the EH&S Office prior to the start of work, to assure that facilities are adequate. 

8.2  Waste Pickup Procedures

• Ensure waste has been labeled and segregated as described in Sections 8.0 and 8.1.
• Completely fill out Form 104 "Radioactive Waste Disposal" and submit to EH&S (mail code 8284)
• EH&S will arrange to have the waste picked up and properly disposed of.
• Authorized User is responsible for maintaining records of radioactive waste pick up (Form 104). 

8.3  Procedures for Decay in Storage  

The RSO may choose to decay radioactive material in storage prior to release as non-radioactive material.  The procedures to be followed are summarized below.

• Isotopes : Only isotopes with half-lives of less than 90 days will be considered for decay in storage.

• Storage Area:  Decay in storage waste will be stored in the campus radioactive waste storage room.  The room is single story, with concrete floors, walls and ceiling.  A locked fence, and a locked and labeled steel door secure the room.  Only the Environmental Health and Safety office and a limited number of senior administrators have access to the room.

• Adjacent Areas:  The nearest occupied area is more than 100 ft away therefore, expected dose rates in the adjacent uncontrolled areas are well below regulated levels.  Only beta and weak gamma emitters (I-125) are currently decayed in storage and the activity decaying is typically a few hundred microcuries.

• Procedures to Ensure Adequate Decay Prior to Disposal: 
• Inventory control is established by labeling every drum with Form 208, Decay in Storage Drum Inventory.  This in combination with Form 104, Radioactive Waste Disposal provides the information required to determine when a waste has been adequately decayed.

• Storage time is generally ten times the half-life of the radioisotope.  When adequate storage time has passed the drum is opened and a survey meter is used to measure activity in individual containers.  If measurements are indistinguishable from background, then all radiation labels are removed or defaced, and the material is released as non-radioactive.

• Segregation Procedures:  Wastes are segregated at generation by isotope and further segregated into solids, liquids and sharps.  A drum is labeled and specifically dedicated for each isotope and pick up date.  Each drum therefore need not be opened until adequate storage time has passed.

• Records:  Disposal records are maintained including Forms 104 and 208.  These forms document dates, activity, isotopes, weights and other relevant information with regard to the decay in storage program. 

IX.   Radiation Producing Machines

9.0  Authorization Procedures

Individuals intending to fabricate or use radiation-producing machines must obtain an Ionizing Radiation Use Authorization (IRUA).  The IRUA is issued by the RSO after review and approval by the Radiation Safety Committee.

• Eligibility:  Persons intending to use radiation-producing machines at CSU Northridge must meet the eligibility requirements specified in section 3.1(a).

• Requirement for Application:  Eligible individuals can obtain a IRUA by submitting the following forms and information:

• "Application for Use of Ionizing Radiation" (Form 101)
• "Statement of Training and Experience" (Form 201) for each person who will be using the radiation producing machine.

The forms should be submitted to the RSO (mail code 8284).  The RSO is also available to assist with completing the forms and addressing any safety issues related to the proposed radiation machine use.

The RSO may also issue an interim approval for routine applications until formal review and approval by the RSC.  Upon formal approval by the Radiation Safety Committee, the Radiation Safety Officer will issue an IRUA. 

9.1  General Safety Provisions

• Posting and Labeling:  Radiation producing machines and areas where these machines are used must have the following posting and labels:
  • All radiation-producing machines must be labeled as such (e.g. "WARNING THIS DEVICE PRODUCES X-RAYS").
  • All entrances to areas where x-ray producing machines are used shall be posted with sign(s) that read "CAUTION X-RAY".
  • A current copy of the CDPH "Notice to Employees" (form 2364) must be posted in any area where radiation-producing machines are used.
  • A copy of the CSUN "Guidelines for the Usage of X-Ray Producing Machines" (Form 301 - Appendix D) must be posted in any area where radiation-producing machines are used.

• Safety Interlocks and warning lights:  Many radiation producing machines will be equipped with safety interlocks, which prevent access to high radiation areas while the machine is operating, and/or safety warning lights which illuminate when the machine is producing radiation.  All persons working with radiation-producing machines must be aware of the significance of these safety devices and must never attempt to bypass or disable.
• Training:  Each individual assigned responsibility for operating the machine must be thoroughly familiar with the procedure guide prior to assuming duties as an operator.  All training conducted shall be documented.

9.2  Machine Location

The equipment should be placed in an area that is not in the main traffic pattern of the laboratory or near other continuously occupied work areas.  A room devoted solely to the radiation-producing machine is ideal, since it may be locked when not in use or during unattended operation.  Proper placement of the machine will direct any scatter or stray beams away from the operator and toward an unoccupied area, preferably an outside wall.  Any change in the location of a radiation-producing machine must have prior approval of the RSO. 

9.3  Monitoring  

Radiation survey meters are required for use of many radiation-producing machines.  The survey meter must be appropriate for the type and energy of radiation produced.  The RSO can recommend appropriate survey meters for specific applications.

After any repairs or modifications to a radiation-producing machine, interlocks, or shielding, the RSO or qualified repairperson must be consulted before operation is resumed to ensure that none of the machine's safety features have been compromised. 

9.4  Relocation or Disposal

Any radiation-producing machine received, sold, disposed of, or relocated must be reported to the RSO.  Reports must include:

• Type of radiation-producing machine
• Manufacturer's name
• Model number
• Serial number
• Year of manufacture
• Maximum energy and maximum flux of current
• Use of application (gauging, irradiation, diffraction, etc.)
• Estimated use per week (in hours)
• Date of the change (e.g. receipt, sale, or disposal)

X.  Emergency Procedures

10.0  Fire

Report Immediately call 911 or Ext. 2111

10.1  General Emergency Actions

• Evaluate level of exposure for emergency response personnel, then assign personal protective equipment appropriate for the tasks required.
• Evacuate personnel from proximity to the spill and segregate them – remove dosimeters.
• Close off the affected area; shut off ventilation if spill is potentially volatile, seal the room(s) if contamination is likely.
• Evaluate:
• The extent of exposure of victims
• The need for bioassay of victims
• The extent of contamination of the facility
• If victim is hurt and must be hospitalized, do a preliminary decontamination prior to release of the patient and inform the hospital of the contamination prior to the patient’s arrival.  The need for this decontamination must be weighed against the patient’s need for immediate care.
• If bioassay is likely, save all samples of blood, urine, stool or vomitus and label with name, date and time.  In any case, save all samples of clothing.
• Keep detailed records of all that occurs.
• Proceed to clean up of radioactive material

10.2  Minor Spill Clean Up

Most spills on Campus will involve, at most, millicurie quantities of radioactive materials.  The following procedures can be used for this type of spill:

• Notify all personnel in the area a spill has occurred.
• Evaluate potential for exposure during clean up and wear appropriate protective equipment.
• Cover liquid spill with inert absorbent material, or dampen dry spill with water to avoid spreading.
• Shut off ventilation if spill is potentially volatile; isolate the room(s) if contamination is likely.
• Determine the extent of contamination and mark boundaries with tape, chalk, rope etc.
• Evacuate any unnecessary personnel from area but do not allow anyone potentially contaminated to leave area before being monitored for contamination.
• Clean spill from the periphery and work inward to prevent spread of contamination.  A survey meter or wipe tests will be required to monitor effectiveness of decontamination (see section 7.0 for contamination survey guidelines).  Use the most mild methods of cleaning first and progress to harsher methods only if the spill cannot be cleaned to less than 220 dpm/100 cm²(roughly 2X background).  Clean-up methods (listed from mild to harsh) include:
• Wiping
• Wiping with water
• Steam
• Soaps, and detergents
• Complexing agents
• Organic solvents
• Inorganic acids
• Acid mixtures
• Caustics
• TSP and scrubbing
• Abrasion
• Sandblasting.
• Put all contaminated materials into plastic bags contained within steel or plastic drums

10.3  Personnel Decontamination

• Define area on body or clothing that is contaminated.
• Remove contaminated clothing immediately to prevent spread of contamination and the possibility of internal contamination.
• If contamination of the skin has occurred, decontamination should not increase penetration of the radioactivity into the body by excessive abrasion of the skin.  Therefore, clean with mildest methods first and progress to harsher methods only if fixed contamination persists.  Clean from outside area of contamination inward to prevent spread of contamination.  The maximum limit on residual contamination of hands, body surfaces, personal clothing and shoes is 0.1 mrad/hr at 2 cm.
• Methods of skin decontamination are listed below starting with the mildest and progressing to harsher methods: flush with water, soap and warm water, mild abrasive soap with soft brush and water, detergent, 50% powdered detergent and 50% cornmeal, complexing solution, mild organic acid (citric acid solution).
• The procedure for decontaminating personnel follows; each cleaning should be monitored with a survey meter to assess effectiveness:
• Flush with water
• Wet gloved hands and work cleaning agent into a good lather before applying to contaminated area
• Wash lather into contaminated area 2 to 3 minutes
• Rinse with warm water
• Repeat the process three or four times
• Progress to a more aggressive method if radiation is still excessive
• Apply skin cream after clean-up to prevent chapping
• Finally, a contamination victim should take a shower and clean the entire body with special attention to hair, hands and fingernails

10.4  Suspected Lost or Stolen Source(s) of Radiation

REPORT:  Immediately contact the Radiation Safety Officer (9-911, X-2401, X-2111).  Be prepared to describe the present situation.