university of virginia office of environmental health & safety radiation...

University of Virginia Office of Environmental Health & Safety

Radiation Safety http://ehs.virginia.edu/Radiation-Safety.html

Radiation Safety Notebook

TABLE OF CONTENTS

§1 OEHS phone/address Listings §2 Authorization to Use Radioactive Material 2.1 Authorization Categories 2.2 Training Requirements 2.3 Application Forms §3 Procurement, Receipt and Inventory of Radioactive Materials 3.1 Ordering Radioactive Material 3.2 Procedure for Opening Radioactive Packages 3.3 Radionuclide Information Sheet 3.4 Laboratory Radionuclide Inventory Recordkeeping §4 Radioactive Waste 4.1 Management and Disposal Procedures 4.2 Radioactive Waste Ticket Instructions §5 Radiation Surveys

5.1 Survey Procedures 5.2 Portable Survey Instruments

5.3 Fixed Counting Systems 5.4 Laboratory Radiation Survey Report Cover Sheet 5.5 Survey Instrument Use Guidance

§6 Adding/Removing Rooms from your Authorization 6.1 Procedure for Commissioning Rooms 6.2 Procedure for Decommissioning Rooms §7 Policy for Use of Radioactive Materials in the Vivarium §8 Personnel Monitoring 8.1 Radiation Dosimeter Use Guidelines 8.2 Radio-bioassay Guidelines

§9 Radiation Emergency Procedures

§10 Security Requirements for Radioactive Material §11 OEHS Correspondence

http://ehs.virginia.edu/Radiation-Safety.html

2

§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:

http://ehs.virginia.edu/Staff.html

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

http://ehs.virginia.edu/Staff.html

Radiation Safety Notebook Rev. 12/2017

§2 AUTHORIZATION TO USE RADIOACTIVE MATERIAL §2.1 AUTHORIZATION 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 User temporarily 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: http://ehs.virginia.edu/ehs/ehs.rs/rs.training.html

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 through the OEHS website. A live lecture can be provided if a request is made to our office.

http://ehs.virginia.edu/ehs/ehs.rs/rs.training.html


§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: http://www.ehs.virginia.edu/rad/rad_forms.html 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.

http://www.ehs.virginia.edu/rad/rad_forms.html


§3.0 PROCUREMENT, 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:

http://ehs.virginia.edu/Radiation-Safety-Order.html

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 [email protected].

http://ehs.virginia.edu/Radiation-Safety-Order.html


§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

RADIONUCLIDE INFORMATION

ISOTOPE

HALF-LIFE

TYPE OF RADIATION

SURVEY INSTRUMENTS LIQUID SCINTILLATION COUNTER (L)

GEIGER COUNTER(M) GAMMA COUNTER (G)

*Preferred method

3H

12.3 Years

Beta L

14C

5730 Years

Beta

L

45Ca

163 Days

Beta

L*, M

35S

87.4 Days

Beta

L

32P

14.3 Days

Beta

M, L

125I

60 Days

Gamma

G*, M (with NaI crystal), L

131I

8 Days

Beta, Gamma

G, M

51Cr

27.7 Days

Gamma

G, M, L

137Cs

30 Years

Beta, Gamma

G, M, L

low energy betas

--

Beta

L

high energy betas

--

Beta

M, L

low energy gammas

--

Gamma

G, M (with NaI crystal)

high energy gammas

--

Gamma

G, M

micro spheres

--

Gamma

M

1 Curie = 2.22 x 1012 dis/min 1 Curie = 3.7 x 1010 dis/sec 1 Millicurie = 2.22 x 109 dis/min 1 Millicurie = 3.7 x 107 dis/sec 1 Microcurie = 2.22 x 106 dis/min 1 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…….

• The inventory must be updated when new material is received.

• The inventory must be updated when material is removed from a stock vial.

• Radioactive material in waste containers must be subtracted from inventory when the waste is removed from the lab by EHS.

• The entry units must be in mCi or µCi; units of volume are not allowed.

• Entries must be made in ink.


§4.0 RADIOACTIVE WASTE §4.1 RADIOACTIVE 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 containing isotopes 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 than 120 days, i.e. Carbon-14 (14C) or Tritium (3H), must be segregated from other radionuclides and 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. • Separate aqueous from organic liquid waste. • Record all chemicals contained in the waste, along with measured pH. • Do not overfill waste containers. • Leave room for potential expansion of the waste. • Do not place solid material (e.g. biological material, filter paper, pipette tips) in your

liquid waste. Obstructions in the spout can create a splashing and disposal hazard. • Try to reduce the amount of acidic waste which can damage containers. • Add bleach or use other methods to neutralize biological liquid waste (e.g. blood,

urine, cells).


§4.1 Use a funnel when pouring liquid into the waste container to prevent spills and minimize contamination on the outside of the container. When washing contaminated glassware, etc. you must collect the first rinse wash water and place in the radioactive liquid waste container. Count a sample of subsequent rinse water if you suspect significant remaining contamination before washing as usual. Never pour radioactive material down the lab sink. Stock Vials, Other Vials or Capped Containers (< 50 ml): Vials and other capped containers with less than 50 ml of liquid may be disposed in the dry solid waste container. Note: Stock vials (with <50ml) may be placed in dry solid waste, however, the lead containers they come in must not go into the waste box. The lead must be kept separate and can be picked up by OEHS as a separate waste item. Old stock vials should not be stockpiled. Dispose of them promptly if they will no longer be used or have expired. Biological Tissue: This waste includes animal bedding and blood soaked items. These items must be packaged to prevent leakage. Sharps must be put in an approved sharps container. Freeze or refrigerate this waste, when possible, until pickup. Radioactive/EPA classified hazardous chemical waste. All labs that generate waste that is both radioactive and is an EPA classified chemical waste must consult our office for proper disposal instructions to ensure that all local, state and federal regulations are followed. Containers that will be used for disposal of mixed hazardous material must be provided by OEHS. Mixed hazardous waste must be clearly described on the waste ticket. Do not place this type of waste in a radioactive waste container. Lead: Lead is a hazardous material and must be separated from other types of waste. Place lead in a box, label as lead waste, and call EHS for pickup. Waste Handling and Disposal Procedures

♦ Package radioactive waste in appropriate containers. OEHS provides

radioactive waste containers upon request, at no cost to the lab. No other containers are permitted to be used unless approved by our office. This reduces the likelihood that radioactive waste will be mistaken for routine, non-regulated trash and disposed of improperly or that the container will leak.

♦ The University of Virginia’s radioactive materials license requires us to

dispose of waste containing nuclides with half-lives greater than 120 days (e.g. Co-57, Co-58, Na-22, Cl-36, Zn-65), by shipment to a licensed disposal facility. OEHS should be consulted on methods to minimize such waste.


§4.1 ♦ Survey waste container for contamination. OEHS must be notified if

contamination is found on the outside of waste containers. When requesting a waste pickup, notify the EHS representative that contamination is present. Note the contamination level in the comment section of the waste ticket. Notify the technicians when they come to pick up the container.

♦ Keep accurate records of the contents of you radioactive waste containers.

Provide OEHS with an accurate estimate of waste activity. Call us if you need assistance with determination of waste activity.

♦ Never store bulk liquid waste uncapped. ♦ Treat bulk liquids to prevent gas formation. Microorganisms should be killed

using bleach or another method. If you plan to combine chemicals that can react to produce excessive heat or gas, consult our office prior to producing the waste.

♦ Biological material must be packaged to prevent leakage and stored in a

freezer prior to pick-up unless prior arrangements have been made with OEHS. Blood contaminated items should be considered biological waste and packaged accordingly.

♦ If you use a Plexiglas shielding enclosure, place waste boxes on blue pads outside of the Plexiglas shielding prior to pick up if space permits. If not, periodically survey the Plexiglas enclosure for contamination.

§4.2 INSTRUCTIONS FOR COMPLETING A RADIOACTIVE WASTE TICKET A Radioactive Waste Ticket must be completed for each container of waste generated. It is a two-part carbonless form. To request pickup of your waste, fax the white copy of each ticket to 2-4921. The yellow copy must be attached securely to the waste container and the white copy must be posted at the entry to the lab prior to pickup. The completed waste ticket must list radionuclides, activity, and waste type as well as other pertinent waste information. Please print all information legibly. The following information is supplied to assist in completing the waste ticket: 1. A space for the signature of the individual completing the waste ticket is located at

the bottom of the form. No waste will be picked up if the signature is missing. The signature confirms that the required survey of the waste container surfaces has been completed and verifies that all information on the waste ticket is correct.

2. Survey the outside of the waste containers before requesting a waste pick-up and record this information on the waste ticket in the space provided. In accordance with DOT regulations, all radioactive waste containers must be certified free of removable surface contamination exceeding 2,200 dpm/100 cm2. Inform the EHS waste technicians when they arrive to pick up the waste if the survey results are


§4.2 3. greater than background. Contaminated waste containers will be encapsulated in

plastic bags by EHS prior to removal. 4. A space is provided for reporting the measured pH of bulk liquid samples. The pH

must be measured using pH paper or other measuring device. Incorrect pH readings will be investigated by OEHS.

§5 RADIATION SURVEYS §5.1 SURVEY PROCEDURES Radiation surveys are performed to locate sources of radiation exposure and to detect removable surface contamination in lab areas or on equipment, personnel and clothing. Surveys are required by regulation and the conditions of our license.

When work with radioactive material is performed in a laboratory, at least one survey is required to be performed and recorded each week.

All required surveys must be recorded in the Radiation Safety Records notebook. Every PI/Lab should have this notebook. Areas and equipment that may be contaminated, such as the primary work bench(s), water baths, centrifuges, etc., used during the radioactive experiment, should be surveyed. The floor in front of the primary work bench, door handles, etc. should also be surveyed. Surveys should be started in primary work areas and expanded radially. If the primary work area is free of contamination, the expanded survey area can be small. If contamination is detected in the work area, the expanded survey may need to encompass the entire laboratory. Areas found to have unacceptable radiation levels or contamination must be shielded and/or cleaned as soon as possible. Radioactive contamination may be labeled with radioactive material warning tape and/or cleaned. Follow-up surveys must be performed to confirm that contamination problems have been corrected. Recording Results Always record surveys. A survey is considered incomplete if it is undocumented. 1. Complete all items on the University of Virginia Laboratory Survey Sheet; 2. Be sure to note the purpose of the survey. A routine weekly survey is different than a

spill response survey. Check the box for routine daily/weekly surveys, after performing a regular weekly survey. Record all non-routine surveys as well. Record results of follow-up surveys as well and note as "Resurvey of spill." This survey confirms that the cleanup was successful.


§5.1 3. Record survey results in blue or black ink and initialing each survey; 4. Use proper units (DPM or mR/hr units only), only pre-approved labs may use mR/hr; 5. record survey results numerically (descriptive expressions such as “not hot” or

“background” are not acceptable); 6. Enter the full date (month, day and year) that the survey was performed. 7. Signature of person who performed the survey The “no work this week box” should be checked if no work is performed during that week. No survey is required if no radiation work has been performed. Alternatively, a written comment may be provided if no work with radioactive material will be performed for a longer period of time (e.g. “No radioactive work will be performed from month/day/year until month/day/year.”) A notation should be made if work was performed and the weekly survey was missed. From a regulatory standpoint, it is better to indicate that a survey was missed rather than make no comment at all or enter a survey result when none was performed. Converting CPM units to disintegrations per minute (DPM) units: Contamination surveys must be recorded in units of DPM in the survey records. Survey results must contain numeric values; descriptive results (e.g. "background") are unacceptable. The equation for converting CPM to DPM is: CPM gross - CPM background = DPM detector efficiency Detector Efficiency: Each detector has a unique efficiency. GMs from the same manufacturer with similar model numbers may have different efficiencies. Instrument efficiencies are determined by OEHS and are noted on the calibration sticker affixed to the instrument. Call EHS if an isotope’s efficiency is unknown GM detectors are not considered acceptable survey instruments for detection of low energy beta emitters. 3H, 14C, 33P, and 35S surveys must be performed using swipes and counting in a liquid scintillation counter. All survey records must be kept until the termination of your authorization. Regulations require that the University maintain all survey and use records indefinitely for the purpose of eventual decommissioning of facilities. At the termination of an authorization, survey records must be provided to OEHS for inclusion in the University-wide decommissioning records file.


§5.2 Portable Survey Instruments Establish your instrument’s normal background reading. Perform this measurement in a non-radioactive material use area and record it on the Survey Report Cover Sheet. Each detection instrument must have a corresponding Cover Sheet and Survey Sheet. Operational Check for GM detectors To ensure the instrument is functioning properly, perform the following operational check each time the instrument is used: 1. Perform a battery check on your instrument (selector switch in the battery check

position). If needle does not move into the acceptable battery check region, stop and replace batteries before using the instrument.

2. Perform a background measurement. 3. Confirm the instrument responds to radiation by using a check source or some other

radioactive item. Calibration Sticker Survey instruments must have current calibration stickers. Laboratory personnel are responsible for calling our office to schedule an instrument for its yearly calibration. A sticker on the side or bottom of the unit indicates the instrument’s date of last calibration, the calibration due date and the initials of the person who performed the calibration. Always check the due date before using the instrument. If the calibration due date has passed, do not use the instrument. Call us immediately to arrange for calibration. The office can provide a loaner if necessary. For liquid scintillation or gamma counters, refer to the unit's instruction manual and/or ask the manufacturer’s representative to perform a calibration. Refer to the owner's manual for additional information on proper use and operation of the survey instrument. Most contamination survey instruments at UVA are calibrated in counts per minute (CPM). If you intend to perform exposure rate measurements, you will require an instrument that has been calibrated in mR/hr. Check the calibration sticker to confirm proper units for measurement. Survey measurements may only be made in the units that the instrument has been calibrated for (i.e. you cannot measure mR/hr with an instrument which has only been calibrated to provide a reading in cpm). Call our office for further assistance. After our office has calibrated your GM, it will be returned with a "Notice of Calibration" memo. Keep this memo in the Radiation Safety Notebook.


§5.3 Fixed Counting Systems (e.g. LSC, gamma counter) Fixed counting systems such as liquid scintillation counters and gamma counters may be needed to count wipes taken to assess potential laboratory contamination. These systems must be serviced and maintained annually by the manufacturer to insure proper operation. Call the manufacturer or EHS for details.

§5.4 Radiation Survey Report Cover Sheet Radiation Survey Instrument Information must be documented. Each survey instrument or detection system in your laboratory requires a separate laboratory radiation survey report cover sheet. Without separate survey sheets, it is difficult for inspectors to determine whether you are using the appropriate instrument for surveying. The following information must be provided on the cover sheet.

1. Geiger-Muller (GM) Counters are required to be calibrated annually by EHS or a

pre-approved calibration company. After each calibration, a report will be returned with the GM and must be kept in this section of the Radiation Safety Records notebook. This report describes the instrument which was calibrated (e.g. manufacturer, model and serial number). It also indicates which units must be used when reading and recording survey results and the efficiencies to be used for selected radionuclides. Efficiencies are also noted on the case of the GM. The normal background, which is a reading taken in a non-radioactive work area, is provided in CPM. The report also provides any special operating instructions. For GM counters this calibration report may be used in place of the Laboratory Radiation Survey Report Cover Sheet.

2. Liquid Scintillation and Gamma Counters should be serviced annually. During this routine maintenance, the factory representative should check that the unit is functioning correctly and provide the owner with efficiency information. It is the responsibility of all users of liquid scintillation and gamma counters to maintain these counters if they are used for required surveys. Complete a Laboratory Radiation Survey Report Cover Sheet for each liquid scintillation and gamma counter.


§ 5.5 Survey Instrument Guidance

The following table provides information on recommended instruments for performing surveys.

Isotope

Type of

radiation

Geiger Counter with Geiger

tube

Geiger Counter with NaI crystal

Liquid scintillation

counter

Gamma Counter

H-3 Beta N N Y N

C-14 Beta N N Y N S-35 Beta Y N Y N P-33 Beta Y N Y N P-32 Beta Y N Y N I-125 Gamma N Y Y Y I-131 Beta, Gamma Y* Y Y* Y Cr-51 Gamma Y* Y Y Y

N = Do not use this instrument Y = Recommended instrument Y* = Not recommended but may be acceptable if detector efficiencies have been

determined.

Although I-125, I-131, and Cr-51 can be detected using a survey instrument with a Geiger Mueller probe attached, the counting efficiencies associated with these nuclides are very low. We recommend using either a sodium-iodide (NaI) probe with the survey instrument or a liquid scintillation or gamma counter for detection of these radionuclides.


§6.0 ADDING/REMOVING ROOMS FROM YOUR AUTHORIZATION §6.1 PROCEDURE FOR COMMISSIONING ROOMS All laboratory areas where radioactive material (RAM) will be used must be approved and “commissioned” for such use. Commissioning must occur before any radioactive material can be moved into the lab or work with material can begin. Each lab director must complete a "Principal Investigator (for Possession and Use of Radioactive Materials) Application" in order to be considered for initial approval to work with RAM. Once approved by the RSC, OEHS will contact the PI to perform a laboratory commissioning. Formerly approved PIs who wish to add rooms to their current authorization must contact EHS either by phone, or e-mail to the RSO to make a formal request. Completion of an “Authorization Amendment Form” may also be required. This form may be located at: http://ehs.virginia.edu/Radiation-Safety-Forms.html. After the request has been approved, the PI or a person designated by the PI will be contacted by a member of the Radiation Safety Office to schedule the commissioning of rooms. Commissioning items include: ♦ Postings -- A Universal Hazard Communication sign with a "Caution - Radioactive

Materials" warning must be posted on all entrances to RAM-use rooms, including cold rooms. Refrigerators, storage cabinets, fume hoods and other fixed equipment must be labeled with a “Caution Radioactive Material” warning label. A State of Virginia “Notice to Employees” posting containing workers' rights, radioactive emergency telephone numbers, etc. must be posted as well.

♦ Radiation Safety Notebook. ♦ Radiation Survey Instrument inventory and calibration (if applicable) ♦ Waste containers (provided by OEHS) ♦ Review of Radiation Safety policies and procedures §6.2 PROCEDURE FOR DECOMMISSIONING A ROOM Only OEHS personnel may remove radioactive material postings and signs, declare a room free of contamination and radioactive material and release the room for non-radioactive work or unrestricted use. Regulations regarding Recordkeeping for Decommissioning, require licensed institutions to maintain, in one central file, a list of all radioactive-use rooms, the radionuclides used both previously and presently in those rooms and reports of spills and other unusual events occurring in those spaces. The PI should notify our office when the decision to decommission a radioactive room is made. Providing us with as much advance notice as possible will ensure that the resources needed to assist you are available. Call our office at 982-4911 to request the decommissioning of radioactive material use laboratory space.

http://ehs.virginia.edu/Radiation-Safety-Forms.html


§6.2 Please provide the following information: 1. PI Name and PI Number. 2. Name of the person to contact (if different from the PI) concerning the

decommissioning survey. 3. Location of the room [include room number and building]. 4. Date requested for the decommissioning. 5. Department Name and address. This information allows us to begin the decommissioning process. Someone from our office will contact you and explain the steps that need to be taken in order to decommission a radioactive room. The following recommendations provide basic guidance for the safe, legal and efficient removal of a room from your authorization. Plan ahead. The activities required for decommissioning take time. You are required to: contact OEHS for removal of all radioactive material (including waste) clean and survey all contaminated radioactive use equipment, survey, decontaminate, and resurvey until the results indicate that the equipment

and room is free of all radioactive material contamination.

OEHS will perform an independent decommissioning survey to confirm the results of your survey. It is not intended to replace your survey. ♦ Reduce the size and number of radioactive material work areas as soon as

possible. The decommissioning process will be easier and have a smaller impact on your work if it can be done in stages. Begin to confine your radioactive material work space. Notify all laboratory personnel to discontinue use of radioactive material in areas that are to be decommissioned.

♦ Record all decommissioning surveys in your Radiation Safety Notebook. ♦ Do not allow unauthorized individuals (e.g. painters, housekeepers, movers, or

outside contractors) into your laboratory before it is completely decommissioned by OEHS. If work is required in your lab before the process has been completed, these individuals must be under immediate supervision at all times.

♦ Consult with OEHS during your surveys. Call us at 982-4911 if you encounter any problems or need assistance during this process.

Remember... Labs or equipment cannot be abandoned without decommissioning. Laboratory personnel are responsible for the decontamination and general cleanup

of the lab. Signs related to radiation and radioactive material may only be posted and removed

by OEHS personnel. The PI is responsible for the lab until the final decommissioning survey is conducted

by OEHS.


§7 Policy for Use of Radioactive Materials in the Vivarium The following policy describes the responsibilities of radioactive material users who utilize space in any of the UVA Vivarium: 1. Room approval: Both the Principal Investigator for radioactive material use and the

vivarium staff must contact Radiation Safety with an approximate start date for radioactive work. Call our office to request approval for work in these areas.

2. Room posting: Only Radiation Safety personnel are authorized to post new radioactive use rooms and provide the proper waste containers. The room must be properly posted before any radioactive material or radioactive animals are brought into the room.

3. Radiation Safety/Precautions: The Principal Investigator is responsible for all aspects of radiation safety in the radioactive-use rooms in the vivarium including: a. Handling all radioactive excreta b. Cleaning all cages contaminated with radioactive material c. Labeling all cages and other items used for radioactive work with radioactive

warning tape d. In lieu of a., b., and c., a PI or Qualified User may provide immediate supervision

of the vivarium staff in these duties. Non-radioactive work (e.g. watering and feeding of animals) can be done without supervision as long as no bottles or trays are removed from the room prior to being surveyed for contamination.

e. Surveying all areas and equipment at the end of the experiment 4. Room decommissioning: Initial cleanup is the responsibility of the researcher.

He/she must notify Radiation Safety at least 3 working days in advance of cleanup. A PI or Qualified User may supervise unauthorized personnel in the cleanup. Upon completion of cleanup, Radiation Safety must be notified. No room postings may be removed or other items released from the room until the room and its contents have been surveyed by Radiation Safety and confirmed to be free of contamination. THE RADIATION SAFETY OFFICE WILL REMOVE ROOM POSTINGS AND RELEASE THE RADIOACTIVE-USE ROOMS FOR NON-RADIOACTIVE WORK.

5. Radioactive waste: It is the responsibility of the researcher to request radioactive waste pickup before the containers are completely full. Do not overfill waste container. Notify EHS for pickup as soon as the container is sealed. Radioactive feces should be treated like any other biological material and called in for immediate removal as radioactive waste. All waste must be called in to Radiation Safety for removal in a timely manner and there should be (1) waste ticket per article of waste to be picked up.

6. Radioactive emergencies: The vivarium staff must notify the PI in the event of a radioactive spill or other radiation related emergency. It is then the PI's responsibility to immediately notify Radiation Safety.


§7 7. Contamination surveys and radionuclide inventory: These records must be

maintained for all vivarium rooms housing radioactive animals. All radiation surveys must be performed in accordance with standard laboratory procedure. Surveys must be performed at least weekly or at increased frequency if directed by Radiation Safety.

8. Bioassays: If necessary, personnel bioassays will be performed as required by the

Radiation Safety Guide. If there are any questions regarding this policy or the procedures to follow when working with radioactive material in the vivarium, please contact our office at 982-4911.


§8.0 PERSONNEL MONITORING §8.1 RADIATION DOSIMETER USE GUIDELINES

You may be required to wear radiation dosimetry while working with radioactive material or other sources of radiation. Information on the UVA radiation dosimetry program may be found on the following website: http://ehs.virginia.edu/Radiation-Safety-Dosimetry.html Before you can be issued a dosimeter, you must complete radiation safety training and complete a dosimeter application. The on-line dosimeter application is available through the above radiation safety webpage. §8.2 RADIO-BIOASSAY GUIDELINES Bioassay (radio-bioassay) means the evaluation of radioactive material in the human body, whether by direct measurement (in vivo counting) or by analysis of collected biological samples, such as urine. Radioactive material users will be subject to bioassay measurements if certain amounts of radioactive material have been or will be used. The conditions under which a bioassay must be performed and the required frequency are a function of the radiotoxicity of the radioisotope in use and the probability of uptake of that material (based on the chemical reactions involved and whether the work is performed in a fume hood, glove box or in an open room). When a determination has been made that bioassays will be required, a baseline evaluation (pre-use measurement) should be performed. Consult the Radiation Safety Guide for Current Bioassay requirements. The Guide is available from the Radiation Safety homepage: http://ehs.virginia.edu/Radiation-Safety.html In addition to individuals handling the material, it may be necessary to perform bioassays on individuals who work sufficiently close to use processes to make intake possible. This may include persons observing or assisting in an iodination procedure. Determination of which individuals require a bioassay will be made by Radiation Safety staff.

http://ehs.virginia.edu/Radiation-Safety-Dosimetry.html




§9 RADIATION EMERGENCY PROCEDURES Spills of quantities of radioactive material normally present in laboratories at the University present little or no immediate external exposure hazard. Of greater concern is the possibility of internal and external contamination of personnel and the spread of contamination into uncontrolled areas. Immediate action should be taken to prevent the spread of contamination unless an injured person requires immediate medical attention, volatile radioactive materials are present, or unacceptable external radiation exposure rates exist. Radioactive spills during weekdays between 8 am and 5 pm, should be handled in the following manner:

For radioactive spills which occur during evening hours, weekends, or holidays:

1. Be prepared to give the operator the following information: Lab location and call back phone

number(s), radioisotope and activity, a brief description of the incident. 2. If you remain in the laboratory, keep the call back phone free in case EHS needs to contact

you. If you must leave the lab, call EHS from your new location. Only leave the lab if required by the emergency or requested by emergency response personnel.

If a radioactive emergency involves a fire, injury or risk to personnel or

property, call 911. EHS will be notified immediately. If there is no fire, injury or risk to personnel or property, confine the spill to the

smallest area possible by using paper towels or other absorbent materials and dispose of as radioactive waste. Do not allow spilled radioactive material to enter any floor drains, if possible. Call EHS at 2-4911 for assistance, not 911.

Call 911 for the appropriate emergency services in the event of a radioactive

emergency that involves fire, injury or risk to personnel or property. Tell the dispatcher that the emergency involves radioactive material. EHS will be notified.

If there is no fire, injury or risk to personnel or property, call EHS for assistance,

not 911.


9.1 Minor spills are those which do NOT result in: external personnel contamination radioactive material ingestion unacceptable external radiation exposure loss of use of laboratory facilities

1. Notify persons in the area that a spill has occurred. 2. Prevent the spread of contamination by covering the spill with absorbent paper.

(Paper should be dampened if solids are spilled). 3. Control access to the spill area as soon as possible by posting warnings on all

entrances into the room and by closing off the affected area to prevent the spread of contamination.

4. If there is no external exposure to laboratory personnel (i.e. clothing, shoes), put on protective clothing (e.g. gloves, shoe covers) and clean up the spill. Clean up the spill using absorbent paper. If you are unsure how to properly clean up the spill, call EHS as soon as possible for assistance. EHS can offer consultation, equipment and assistance.

- Carefully fold the absorbent paper with the clean side out and place in a plastic bag for transfer to a radioactive waste container. Put contaminated gloves and any other contaminated disposable material in the bag and then call EHS to report the incident.

4. If there is radioactive contamination on clothing, shoes, or personnel, call EHS for assistance as soon as possible. Potentially contaminated personnel must not leave the area until they have been surveyed by either EHS or trained laboratory personnel.

5. If radioactive material goes down a floor drain or spills out of the authorized room into unauthorized areas, call EHS as soon as possible for assistance.

6. Survey the area with an appropriate low-range radiation detector survey meter or other appropriate technique. Check the area around the spill for contamination. Also check hands, clothing, and shoes for contamination. All clean-up surveys must be documented in your Laboratory Survey Records.

7. Report the incident to the Radiation Safety Officer (RSO) promptly. Allow no one to return to work in the area unless approved by the RSO. A written

report must be submitted to EHS within five (5) working days of the incident for all spills that involve contaminated personnel or involve unauthorized areas.

a. Cooperate with the RSO and/or the RSO's staff (e.g., investigation of root cause, provision of requested bioassay samples). Follow the instructions of the RSO and/or the RSO's staff (e.g., decontamination techniques, surveys, provision of bioassay samples, requested documentation).


9.1 Major spills of liquids or solids are those that result in: external personnel contamination radioactive material ingestion unacceptable external radiation exposure loss of use of laboratory facilities 1. Notify other personnel in the room where the spill occurs. 2. Clear the area. If appropriate, survey all persons not involved in the spill and vacate

the room. 3. Prevent the spread of contamination by covering the spill with absorbent paper

(paper should be dampened, if solids are spilled), but do not attempt to clean it up. To prevent the spread of contamination, limit the movement of all personnel who may be contaminated.

4. Shield the source only if it can be done without further contamination or significant increase in radiation exposure.

5. Close the room and lock or otherwise secure the area to prevent entry. Post the room with a sign to warn anyone trying to enter that a spill of radioactive material has occurred. Stay in the immediate vicinity of the affected room to prevent the spread of contamination and provide EHS with information and assistance. Control access to the spill area as soon as possible by posting warnings on all entrances to the room and by barricading the affected area to prevent the spread of contamination.

5. Notify the RSO/EHS immediately. EHS will assist you in planning the decontamination procedures.

6. Survey all personnel who could possibly have been contaminated. Decontaminate personnel by removing contaminated clothing and flushing contaminated skin with lukewarm water and then washing with a mild soap. Begin personnel surveys to determine if individuals are contaminated. Assume that all persons in the affected area may be contaminated. Do not allow anyone to leave the immediate vicinity until EHS has confirmed the results of your preliminary surveys.

7. Allow no one to return to work in the area unless approved by the RSO/EHS. EHS will control access to all areas where the exposure rate is greater than 2 mR/hr. Your detector must be calibrated in units of mR/hr to obtain a measurement in mR/hr; most UVa survey instruments are calibrated in units of CPM. EHS maintains instruments calibrated to perform exposure rate measurements (mR/hr).

8. With permission and possible assistance by EHS, put on protective clothing provided by EHS and begin decontamination and cleanup.

9. All clean-up surveys must be documented in your Laboratory Survey Records.


9.1 10. A written report must be submitted to EHS within five (5) working days of the

incident for all spills that involve contaminated personnel or involve unauthorized areas.

11. Cooperate with the RSO and/or the RSO's staff (e.g., investigation of root cause, provision of requested bioassay samples). Follow the instructions of the RSO and/or the RSO's staff (e.g., decontamination techniques, surveys, provision of bioassay samples, requested documentation).

Incidents Involving Radioactive Dusts, Mists, Fumes, Organic Vapors, and Gases 1. Notify all personnel to vacate the room immediately. 2. Shut down ventilation system, if possible, unless it is determined that the room

ventilation system needs to be used to clear the air for access purposes. 3. Vacate the room. Seal the area, if possible. 4. Notify the RSO immediately. 5. Ensure that all access doors to the area are closed and posted with radiation

warning signs, or post guards (trained) at all access doors to prevent accidental opening of the doors or entry to the area.

6. Survey all persons who could have possibly been contaminated. Decontaminate as directed by the RSO.

7. Promptly report suspected inhalations and ingestions of licensed material to the RSO.

8. Decontaminate the area only when advised and/or supervised by the RSO. 9. Allow no one to return to work in the area unless approved by the RSO. 10. Cooperate with the RSO and/or the RSO's staff (e.g., investigation of root cause,

provision of requested bioassay samples). Follow the instructions of the RSO and/or the RSO's staff (e.g., decontamination techniques, surveys, provision and collection of bioassay samples, requested documentation).

Minor Fires 1. Immediately attempt to put out the fire by approved methods (e.g., fire extinguisher)

if other fire hazards or radiation hazards are not present. 2. Notify all persons present to vacate the area and have one individual immediately

call the RSO and fire department (as instructed by RSO). 3. Once the fire is out, isolate the area to prevent the spread of possible

contamination. 4. Survey all persons involved in combating the fire for possible contamination.


9.1 5. Decontaminate personnel by removing contaminated clothing and flushing

contaminated skin with lukewarm water, then washing with a mild soap. 6. In consultation with the RSO, determine a plan of decontamination and the types of

protective devices and survey equipment that will be necessary to decontaminate the area.

7. Allow no one to return to work in the area unless approved by the RSO. 8. Cooperate with the RSO and/or the RSO's staff (e.g., investigation of root cause,

provision of requested bioassay samples). Follow the instructions of the RSO and/or the RSO's staff (e.g., decontamination techniques, surveys, provision of bioassay samples, requested documentation).

Fires, Explosions, or Major Emergencies 1. Notify all persons in the area to leave immediately. 2. Call 911 3. Notify the RSO and other facility safety personnel. 4. Upon arrival of firefighters, inform them where radioactive materials are stored or

where radioisotopes were being used; inform them of the present location of the licensed material and the best possible entrance route to the radiation area, as well as any precautions to avoid exposure or risk of creating radioactive contamination by use of high pressure water, etc.

5. Cooperate with the RSO and/or the RSO's staff (e.g., investigation of root cause, provision of requested bioassay samples).

6. Allow no one to return to work in the area unless approved by the RSO. Follow the instructions of the RSO and/or the RSO's staff (e.g., decontamination techniques, surveys, provision of bioassay samples, requested documentation).


§10 SECURITY REQUIREMENTS FOR RADIOACTIVE MATERIAL

The NRC, State of Virginia and the University of Virginia are all concerned about the security and accountability of radioactive material. Radioactive material must be under the direct control of authorized individuals or secured to prevent unauthorized access or removal. You must keep your doors and any storage or equipment which contains radioactive material locked, when you or other authorized individuals are not present. The Radiation Safety Committee requires that each PI submit a security plan for his/her radioactive material work area(s). The Office of Environmental Health & Safety will routinely inspect these areas for security violations. The University of Virginia’s Radioactive Materials Security Policy is explained in our online document titled “Answers to Frequently Asked Questions Regarding the Security of Radioactive Material.” http://ehs.virginia.edu/Radiation-Safety-Security.html

http://ehs.virginia.edu/Radiation-Safety-Security.html


§11

OEHS CORRESPONDENCE

You may keep all correspondence from OEHS in this section.

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