Printed on: 12/15/2018. Please go to http://policy.umn.edu for the most current version of the Policy or related document.
Procedure

Radioactive Material Use

Administrative Procedure

The use of radioactive materials at the University is regulated under the State of Minnesota Radioactive Materials Rules and /or the U.S. Nuclear Regulatory Commission (Title 10 Code of Federal Regulation).

The University maintains a medical use license of broad scope (Type A) issued by the Minnesota Department of Health and a specific license of broad scope issued by the U.S. Nuclear Regulatory Commission for the use of radioactive materials on all campuses, institutes and experiment stations within the State of Minnesota and on Lake Superior.

The All-University Radiation Protection Committee (AURPC) in conjunction with the Department of Radiation Safety (DRS) reviews and approves all use authorizations. The AURPC has reviewed and approved Radioactive Materials Procedures that provide guidance and instructions to prospective and current users of radioactive materials. All users of radioactive materials must comply with these procedures.  DRS conducts routine audits and inspecetions of all use areas to document compliance with applicable rules and regulations.

Radioactive Materials Procedures

Permit to use radioactive materials

The Guide for Completing Permit Application, Permit Amendment Form and the Radioactive Materials Permit Application are available at Permits for Using Materials.

All individuals wishing to establish a permit, or amend an existing permit for the use of radioactive materials must complete the appropriate on-line form for the possession and use of radioactive materials available here: https://www.dehs-tools.umn.edu/Radiologistix/

Required supporting documentation includes: description of each radionuclide protocol and safe handling procedures, documentation of completion of radiation protection training (see Radioactive Materials Safety Training below), documentation of adequacy of radiation shielding and radiation survey instrumentation for radionuclides requested, and description of contamination control protocol.

DRS staff will contact the applicant to review application and documents, use locations, personnel radiation dosimetry (see Radiation Dosimeter assignment and use below), radioactive waste containers needs, etc. DRS staff will also review the safe use of radioactive materials procedures and train the designated permit holder trainer.

The permit application will be reviewed by the Permit Review Subcommittee (PRS). Following approval by the PRS, DRS staff will contact permit applicant.

Radioactive materials safety training

All University faculty, staff, and students who require access to areas where radioactive materials are used or stored must complete the appropriate on-line Radioactive Material Training modules.

Radiation dosimeter assignment and use

State and Federal regulations require the assignment of personnel radiation dosimeters to individuals who are likely to be exposed to greater than applicable radiation dose limits. Guidance on determination of who needs a dosimeter(s) and how to obtain these is available at Dosimetry. Each permit holder should review this information or contact DRS staff to determine if personnel radiation dosimetry is required.

Order / receive radioactive materials

State and Federal regulations require adequate security and control of access to radioactive materials. The University has a centralized program for the ordering and receipt of radioactive materials managed by DRS staff. Details on how to order are available on the Radioactive Materials Ordering website.

DRS staff will perform a compliance check of the permit to assure that the radioactive materials are authorized and that there are no compliance violations under the permit.

Upon receipt of the radioactive material DRS staff will survey all shipments for compliance with MDH, NRC and DOT regulations, and then deliver them to the authorized, secured use location.

Proper collection, packaging and request for radioactive waste pick-up

State and Federal regulations require that all radioactive wastes be managed and disposed in accordance with license conditions. The University has established a centralized radioactive waste collection, processing and final disposal program through DRS. The permit holder is responsible for proper segregation, collection and record-keeping within the lab.

Contact DRS staff for details on required procedures for collection, packaging, label, transport and disposal of radioactive waste generated within the University.

If the radioactive waste is combined with a hazardous waste, (e.g. flammable solvent, poison, etc.), a hazardous waste manifest must also be completed and submitted to DRS.

Incidents with radioactive materials and emergency management

DRS staff are available to assist with controlling contamination and cleaning up spills. There are no negative consequences for reporting a spill. If a suspect incident may have occurred, call DRS – see contact section of the policy. Review this site for details of what to do in an incident involving radiation,

To maintain the health and safety of all University staff and students and to remain compliant with state and federal regulations for exposure of ionizing radiation and contamination incidents, DRS staff must be involved in certain spills or potential personnel contamination incidents. These incidents include:

  • contamination of an individual's skin or clothes (including shoes)
  • ingestion, absorption or inhalation of radioactive materials
  • contamination of work surfaces outside the immediate workstation (including bench tops, fume hood surfaces, lab equipment or furniture, and any floor contamination)

Record Keeping and Reporting Procedures and Requirements

Required Record Keeping

Permit holders for radioactive materials are required to keep up-to-date records for the following:

  • records of receipt & use of each radioactive material stock vial
  • records of disposal into each radioactive waste container
  • records of radiation contamination survey results of storage/use areas
  • new employee and annual refresher training records for all staff who are granted unescorted access to the permit holder’s posted labs

Required Incident Reporting

Permit holders for radioactive materials holders are required to report the following:

Immediately report incidents involving:

  • radionuclide spills
  • personnel contamination
  • lost or stolen materials
  • accidental radiation exposures,
  • improper disposal of radioactive materials
  • in-lab contamination levels in excess of 1000 dpm/100cm2

Report within one working day, incidents involving:

  • a lost or stolen radiation dosimeter
  • a declared pregnant worker
  • an inoperable radiation survey instrument
  • a removable contamination level in excess of 250 dpm/100 cm2

See the contacts section of Administrative Policy: Radiation Safety for telephone and email information.

Compliance and Enforcement Procedure

The State/Federal license conditions require the establishment of a compliance enforcement procedure that is approved and implemented by the AURPC. This procedure incorporates three levels of enforcement action by AURPC. Higher levels are initiated only if there is no correction of a previous level within time frame designated by AURPC, or if there are repeat offenses.

The first level involves a hold on radioactive materials orders until the non-compliance item has been satisfactorily resolved.

The second level, involves the permit holder responding to the AURPC with a satisfactory resolution of the non-compliance item.

The third level involves the permit holder appearing before the AURPC to give an explanation of failure to comply, and possible revocation of the permit if there is unsatisfactory resolution.

Document Feedback