ADMINISTRATIVE PROCEDURE

Radioactive Material Use

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 Radiation Protection Division (RPD) of the DEHS review and approve all use authorizations, and conduct routine audits and inspections of all use areas to document compliance with applicable rules and regulations. 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.

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 and submit the appropriate form for possession and use of radioactive materials to:

Environmental Health and Safety
University of Minnesota
Del Code 1171
W-140 Boynton Health Service
410 Church Street SE
Minneapolis, MN 55455
ATTN: Radiation Protection Division
(via email: dehs@umn.edu)

The applicant must submit the form and required supporting documentation to the Radiation Protection Division (RPD). 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.

RPD 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. RPD staff will also review the radioactive materials procedure manual and train the designated permit holder trainer.

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

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 RPD 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 the RPD. Details on how to order are available on the Radioactive Materials Ordering website.

RPD 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 RPD 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 the RPD. The permit holder is responsible for proper segregation, collection and record-keeping within the lab.

The Radioactive Waste Manual contains 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 the RPD.

Incidents with radioactive materials and emergency management

The RPD is 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 the RPD – 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, the RPD 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
  • records of quarterly reports of inventories to RPD (includes copy of survey results for each calendar quarter)
  • new employee and annual refresher training records for all staff who are granted unescorted access to the permit holder’s posted labs

Forms used in record keeping and reporting are available on the Radiation Forms page.

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.

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