ADMINISTRATIVE POLICY

Radiation Safety

Responsible University Officer: Vice President for University Services (Interim)
Policy Owner: Assistant Vice President for University Health and Safety
Policy Contact: Brian Vetter

POLICY STATEMENT

University of Minnesota (University) faculty, staff, and students must comply with federal and state regulations and University policies and procedures when conducting research, clinical and teaching activities with, or storage of, radioactive materials and ionizing radiation producing devices. This also applies to faculty, staff and students using radiological materials or devices under grants and contract to the University at off-campus sites.

Non-University entities renting, leasing or otherwise using University property, equipment or facilities, and that are using or storing radiological material or devices are subject to the requirements of this policy, including inspection of their storage, use, and handling facilities.

These regulations include (detailed in the procedures):

  • Permits for the use of radioactive materials
  • Radiation safety training
  • Registration of ionizing radiation producing devices
  • Proper collection, packing and request for radioactive waste pickup
  • Record keeping
  • Incident reporting

Faculty, staff, and students working with radioactive materials and radiation producing devices are responsible for attending required training and following established procedures.

Principal Investigators (PIs) must submit required documentation and receive approval by the All-University Radiation Protection Committee (AURPC) prior to ordering and use of radioactive materials. They are responsible for maintaining a current inventory of radioactive materials, determining training requirements, and enforcing radiation safety policies and procedures.

Permit holders for radioactive materials are responsible for assuring the safe, secure use and storage, and proper disposal of radioactive materials authorized under the permit. They must maintain an inventory of radioactive materials and receive approval from the Radiation Protection Division for any modifications to activities, use or storage locations.

The Department of Environment Health and Safety (DEHS) must be notified immediately when there is an accident involvingionizing radiation sources.

Colleges and departments are responsible for any fines or penalties resulting from their unit’s failure to comply with external radiation regulations. They are also responsible for the facilitation of inventory maintenance and inspections.

The AURPC will establish compliance procedures relating to the safe use of ionizing radiation sources, and will enforce federal, state and University requirements.

REASON FOR POLICY

To implement Board of Regents Policy: Health and Safety by providing a framework to establish and maintain safe, compliant, and responsible use of these sources.

In compliance with federal and state requirements, the University holds licenses that require the University to have policies and procedures to regulate safe use and storage of radioactive materials and devices.

PROCEDURES

FORMS/INSTRUCTIONS

APPENDICES

FREQUENTLY ASKED QUESTIONS

CONTACTS

Subject
Contact
Phone
Fax/Email
Primary Contact(s)
612-626-5247, 612-626-6002
Radiation Protection Division – Twin Cities
Brian Vetter
612-626-6002
612-625-1608
rpd@umn.edu
Environmental Health & Safety - Duluth
Laura Lott
218-726-6917
218-726-7139
ehso@d.umn.edu
Environmental Health & Safety – Morris
Dale Livingston
320-589-6106
Environmental Health & Safety – Crookston
Thomas Feiro
218-281-8300
218-281-8050
tfeiro@umn.edu
Environmental Health & Safety - Rochester
Gail Sauter
507-258-8009
507-258-8004
saute008@umn.edu

DEFINITIONS

All-University Radiation Protection Committee (AURPC)
The U.S. Nuclear Regulatory Commission (NRC) and Minnesota Department of Health (MDH) licensing regulations require the existence of this committee. It is made up of two sub-committees: the Permit Review Subcommittee and the Human Use Subcommittee.
Ionizing Radiation
Ionizing radiation has the ability to remove electrons from atoms, thus creating electrically charged ion pairs. Machines, such as medical or dental X-ray units, can produce ionizing radiation or it can come from the spontaneous decay of radioactive material.
Institutional Review Board (IRB)
The committee established by the president or delegate in accordance with federal regulations to review University research involving human subjects.
Permit holder for radioactive materials
The principal investigator or manager named as the applicant on an AURPC issued radioactive materials use permit.
Principal Investigator (PI)
The individual or individuals primarily responsible for and in charge of a sponsored project.
Radiation Protection Officer (RPO)
Directs the Radiation Protection Division (RPD) of the Department of Environmental Health and Safety (DEHS). The Radiation Protection Officer staffs the All-University Radiation Protection Committee.
Registrant for ionizing radiation producing devices
Administrator/Manager named on Minnesota Department of Health registration.
MN Department of Health - Radiation Control Section (MDH)
State agency that promulgates and enforces rules for the safe use and licensure of radioactive materials within the State of Minnesota. MDH also promulgates and enforces rules for the safe use and registration of ionizing radiation producing devices within the State of Minnesota.
Sponsored Project
An externally funded activity that is governed by specific terms and conditions. Sponsored projects must be separately budgeted and accounted for subject to terms of the sponsoring organization. Sponsored projects may include grants, contracts (including fixed price agreements), and cooperative agreements for research, training, and other public service activities.
U.S. Nuclear Regulatory Commission (NRC)
Federal agency that promulgates and enforces regulations (Title 10 Code of Federal Regulations) for licensure and safe use of radioactive materials at locations where NRC maintains jurisdiction.

RESPONSIBILITIES

Vice President for University Services
Provide resources, support and funding to facilitate the University's compliance with this policy and reports the University's performance to the Board of Regents on a periodic basis.
All-University Radiation Protection Committee (AURPC)
Established to serve as the federal and state mandated radiation safety oversight and compliance enforcement committee for University uses of radiation sources. The AURPC is responsible for review and approval of applications for radioactive materials use permits and applications for research use of radiation in human subjects. The AURPC also enforces compliance with applicable rules and regulations by the authorized users of radioactive materials. The chairperson of this committee or its subcommittees will not be a major user of sources of ionizing radiation at the University. The University President appoints members of the committees. No member is allowed to vote on any committee action directly relating to the approval of his or her application for use of sources of ionizing radiation.
Dean/Department Head
Communicate this policy and procedures to affected staff and students, support programs implementing this policy, and provide resources for units to comply with this policy.  Colleges and units are responsible for any fines or penalties resulting from their unit's failure to comply with external radiation regulations. These administrators are responsible for the facilitation of inventory maintenance and inspections. They must be aware of the potential and actual use of radioactive materials or radiation producing devices used in research, teaching, or medical treatment in their department or college.
Department of Environmental Health and Safety (DEHS)
Provide comprehensive services that support and help protect faculty, staff and students and minimize the impact of their activities on the surrounding environment and community. DEHS facilitates compliance with all federal, state, regional, county and city regulations that pertain to use of radiation sources including training, monitoring and reporting. DEHS is the liaison between the University community and the regulatory agencies. DEHS is responsible for keeping up to date with changing regulations, and for developing comments on proposed regulatory changes that may impact the University's research, clinical and educational community.
Principal Investigator (PI)
Must submit applications for use and storage of radioactive materials, and receive approval by the All-University Radiation Protection Committee prior to ordering and use. They are responsible for maintaining a current inventory of radioactive materials, available at all times for audit/review upon request by the RPD. They are responsible for determining training requirements for staff involved in research projects and for enforcement of radiation safety policies and procedures. PIs must also notify RPD prior to acquiring devices that produce ionizing radiation, in order to satisfy requirements of the Minnesota Department of Health on use of such devices.
Permit holder for radioactive materials
Responsible for assuring the safe, secure use and storage, and proper disposal of radioactive materials authorized under the permit. They must maintain an inventory of radioactive materials and receive approval from the Radiation Protection Division of any modifications to activities, use or storage locations.
Radiation Protection Officer (RPO)
Has the training, knowledge, authority, and responsibility to apply appropriate radiation protection practices according to federal and state regulations on behalf of the University. The radiation protection officer must agree in writing to be responsible for implementing the radiation protection program. The University must provide the radiation protection officer sufficient authority, organizational freedom, time, resources, and management prerogative to:
  • identify radiation safety problems
  • initiate, recommend, or provide corrective actions
  • stop unsafe operations
  • verify implementation of corrective actions
Registrant for radiation producing devices
Responsible for the registration and safe use of ionizing radiation producing devices used in approved locations. They must ensure the secure use and storage of radiation producing devices and receive approval from the Radiation Protection Division of any modifications to use or storage locations.
Staff, faculty, and students
Every employee working with radioactive materials and radiation producing devices is responsible for attending required training and following established procedures. Accidents must be reported immediately to DEHS.

RELATED INFORMATION

HISTORY

Amended:
July 2014 – Comprehensive Review. Minor Revision. Minor changes to clean up language throughout the policy. Text updates to the Human Use of Ionizing Radiation Procedure to reflect the new web-based system.
Effective:
April 2010
Document Feedback
Date Revised
July 2014
Date Effective
April 2010