The purpose of this manual is to inform the university community in a concise user-friendly manner about the rules and regulations pertaining to the safe use of ionizing radiation. It is important that all persons who work in radiation-handling laboratories adhere to these procedures so as to ensure that safe working conditions are present. Safety comes from a partnership of knowledge and trust between the users and the regulators. The Radiations Safety Officer (RSO) looks forward to working with radiation handlers to ensure safe working conditions so that the university’s research and educational mission can be met.

The RSO has supplements to this manual for use by the university community. They contain detailed information and helpful hints on the following subjects:

Standard Operating Procedures for X-ray Producing Machines

Policy for Pregnant Radiation Workers at UCF

Standard Operations Procedures for:

Hydrogen-3

Carbon-14

Sulfur-35

Phosphorus-32

Phosphorus-33

Iodine-125

Selenium-75

The RSO can advise labs about setting up, purchasing radiation detectors, safety procedures, and answer safety related questions.

The procedures listed in this manual are required by law. Failure to follow any procedures is considered a violation that must be corrected in a time commensurate with the severity of the violation. Failure to correct the violation, or repeat violations, may lead to a suspension of radiation handling privileges and the possible loss of the university’s license to use radioactive materials.

CHAPTER 1 REGULATORY AUTHORITIES

THE RADIATION SAFETY OFFICER (RSO)

Renea Carver

The Radiation Safety Officer oversees the use of ionizing radiation on campus to ensure compliance with federal, state, and university regulations to protect employees, students, the environment, and the public.

The Radiation Safety Officer manages the radiation safety program. Responsibilities of the Radiation Safety Officer include:

License amendment changes through the State Office of Radiation Control

Approval of requisitions for purchase of radioactive material/ensure that radioactive materials are used only by individuals who are authorized by the license

Receipt/shipping of Radioactive Materials (RAM)

Radioactive waste management

Ensure that all terms and conditions of the license and these regulations are complied with

Ensure that the sealed sources are leak tested timely and as prescribed.by the manufacturer or by the license

Ensure that all individuals with mandatory dosimetry requirements use the dosimetry correctly.

Maintain all records required by the license and these regulations.

Ensure that radioactive materials are properly secured against unauthorized access or removal

Serve as a contact with the department for events such as the loss, theft or damage of radioactive material

Ensure that all users read and understand the licensee's emergency, operating and radiation safety procedures.

The principle of ALARA (As Low As Reasonably Achievable) is the basis for the university’s radiation safety program. ALARA obligates the RSO to conduct the safety program in such a way as to minimize personnel radiation exposure. The university ALARA policy is available at the Radiation Safety Office. An annual ALARA report will be submitted to all authorized users and the Radiation Safety Committee for review.

UCF’s ALARA policy is posted at http://www.ehs.ucf.edu/radiation/RCforms/ALARA.html

THE RADIATION SAFETY COMMITTEE (RSC)

The Radiation Safety Committee is charged with reviewing new protocols and recommending safety policies and procedures. The primary duty of the committee is to provide advice to the RSO in an effort to keep the university in compliance with the requirements of the State of Florida. The committee will perform an ALARA review on an annual basis to discuss any modifications or improvements to the ALARA program.

STATE OF FLORIDA, DEPARTMENT OF HEALTH, BUREAU OF RADIATION CONTROL

This agency is responsible for issuing our Radioactive Materials License, No. 628-1. The license requires that UCF follow regulations as specified in the Florida Administrative Code, Chapter 64E-5, Control of Radiation Hazards Regulations.

The State Office of Radiation Control is authorized to conduct inspections of licensees and to issue citations for violations. Citations may carry penalties such as fines, license restrictions, and license suspensions.

CHAPTER 2 HOW TO BECOME AUTHORIZED TO USE

RADIOACTIVE MATERIALS (RAM)

HOW TO BECOME AN AUTHORIZED USER

Faculty who need to procure radiation sources for research and/or teaching purposes must be approved by the Radiation Safety Officer. Applicants for authorized user status must fill out the RC-1 Application for Authorization to Possess and Use Radioactive Material form. This form can be obtained from the RSO. In addition to the RC-1, it is advisable to submit protocols/procedures that will be used in the lab.

The information will be sent to the Office of Radiation Control in Tallahassee for final approval and will amend our license reflecting the changes. Approximately one month is needed for this process once the material is sent. In order to prevent delays in authorization, applicants should be as specific as possible when filling out the form. The Radiation Safety Officer can assist with this process.

Authorized users and graduate students who can show experience with isotope usage are not required to attend the radiation safety training class. However, indoctrination into UCF’s radiation policies and practices is required. During indoctrination training, the Radiation Safety Officer discusses the university’s policies and procedures regarding radiation, required record keeping forms, and presents authorized users with a radiation records notebook for their laboratory. All new authorized users and graduate students are required to sign the RC-7 Occupational Dose Limits for Adults and the RC-8 Instruction Concerning Prenatal Exposure Risk forms.

HOW TO BECOME AUTHORIZED TO HANDLE RADIATION

All personnel who handle radiation for research or teaching purposes must meet the requirements set by the Radiation Safety Office. The RSO provides basic safety education to all new radiation workers on campus. The training is approximately two hours in length. A radiation safety video is shown, followed by a presentation that discusses biological effects, dosimetry, instrumentation, contamination surveys, regulations, and responsibilities. A quiz is given and participants must receive at least 70% in order to pass. Workers are also required to sign the RC-7 and RC-8 forms.

RSO delivered training includes:

applicable regulations
storage and transfer, or use of sources of radiation
health protection problems associated with exposure to radiation or radioactive material
precautions or procedures to minimize exposures
purposes and functions of protective devices
instruction to observe all policies and procedures
instruction of worker responsibility to report unsafe conditions to the RSO
contacts and procedures in the event of emergency or exposure
instruction on conditions in which radiation exposure reports shall be furnished to workers

CHAPTER 3 RESPONSIBILITIES OF AUTHORIZED USERS

AUTHORIZED USERS ARE RESPONSIBLE FOR THE FOLLOWING:

Assuming ultimate responsibility for radiation safety in the laboratories under their authorization.

Using only radionuclides and radiation sources approved by the RSO and the RSC.

Making sure that all laboratory personnel are approved/trained by the RSO before handling radiation.

Requiring all personnel using radiation under their authorization to follow radiation safety procedures and regulations listed in this manual.

Performing or designating an approved radiation handler to test for contamination resulting from the use of unsealed radiation sources.

Correcting violations that occur in laboratories used under their authorization. Failure to correct violations may lead to suspension of radiation handling privileges.

Managing radioactive contaminated wastes in the laboratories under their authorization per procedures in Chapter 5 of this manual.

Notifying the RSO before using new laboratory space for radiation handling, or when laboratory space is no longer used for radiation handling.

Notifying the RSO prior to transferring radiation sources to other laboratories, both on and off campus.

Posting monthly dosimetry reports in the laboratory.

Advising pregnant radiation workers to meet with the RSO to discuss pertinent safety procedures and guidelines.

Assuring RAM’s under their control are stored in a secure area.

CHAPTER 4 RESPONSIBILITIES OF RADIATION WORKERS

RADIATION WORKERS ARE RESPONSIBLE FOR THE FOLLOWING:

Complying with radiation safety procedures and regulations.

Keeping exposures as low as reasonably achievable (ALARA).

Reporting any expected overexposures.

Keeping dosimeters in the designated area in the lab when not being worn.

Notifying the RSO if the worker wishes to declare pregnancy.

When issued personal dosimetry, wearing the dosimeter at all times when working with or near radioactive materials.

Ensuring that daily and weekly contamination surveys of the work areas are done when radioactive materials are used.

Filling out Isotope Log Inventory form RC-13 upon receipt of new isotopes. Each time material is removed from the vial that amount must be recorded on the form.

CHAPTER 5 RADIATION PROCEDURES

PROCURING RADIOACTIVE MATERIAL

The RSO must approve all purchases of radioactive material. Arrangements can be made to establish a blanket purchase order. The investigator purchasing the radionuclide must be on the license as an authorized user for the material being ordered and must be sure not to exceed the amounts specified in the license. All new laboratories using radionuclides must be inspected by the RSO prior to ordering radioactive material.

The RSO must be notified each time radioactive material is ordered. All packages must be shipped to:

Renea Moser

Environmental Health and Safety

Libra Drive Bldg 16-Physical Plant

4000 Central Florida Blvd.

Physical Plant, Room 102

Orlando, FL 32816-3500

RECEIVING RADIOACTIVE MATERIAL

All packages will be received by the RSO or trained designee in order to check contents, package integrity, and check for leakage. The packages will then be delivered to the requesting laboratory. If a package is inadvertently delivered directly to the lab, notify the RSO at once. Do not open or use if the package has not been properly checked in by the RSO.

See http://www.ehs.ucf.edu/Radiation/receipt.pdf

TRANSFER OF RADIOACTIVE MATERIALS

Do not transfer radioactive materials to another person, on or off campus, without approval of the RSO. A RC-4 form (Materials Transfer) is required.

The RSO must ensure that the receiver of the radioactive materials is authorized by the RSO and the state.

The transfer of radioactive materials off campus must comply with Department of Transportation regulations. The RSO or trained designee must check all shipments of low-level radioactive materials or waste.

Notification to the Bureau of Radiation Control must be made 48 hours prior to off-campus shipment of low-level radioactive waste.

Mandatory Training Requirements for Radioactive Material Transportation

Any shipping or transportation activities regulated by 49CFR will be performed by persons with appropriate DOT Hazardous Material training. Training is to be completed within 90 days of hire (or commencement of regulated activity) and needs to be refreshed every 3 years. Training certification is to be retained for the duration of employment plus 90 days.

STORAGE OF RADIOACTIVE MATERIALS

Radioactive materials/waste must be stored in containers that provide adequate shielding for the isotope being stored.

Radioactive materials/waste must be stored separately according to isotope.

Liquid radioactive material is to be stored in sturdy plastic containers, not glass, to lessen the chance of breakage. The container must have a screw-top lid. Beverage containers should not be used. The container should be labeled as to content including isotope and chemical constituents.

Radioactive material must be stored in refrigerators, cold rooms, freezers or fume hoods that are properly labeled. The RSO will place a sign on all refrigerators, cold rooms, or freezers used to handle or store radioactive material indicating that no food or drink is to be stored within.

Radioactive materials must be stored in a secure area unless under the direct supervision of an approved worker or authorized user.

Volatile radioactive materials must be stored (and used) in a properly functioning glove box or fumehood with exhaust to outside atmosphere.

SIGNS, LABELS and POSTINGS

All signs and labels will use the conventional radiation caution colors consisting of purple or magenta on a yellow background. The only symbol to be used is the conventional three-blade design. The RSO can provide signs and labels; however, it is the laboratory’s responsibility to obtain warning tape.

A sign indicating “Radioactive Materials” must be posted on the door to any radiation-handling laboratory or storeroom. No eating or drinking is allowed in these rooms unless an area has been designated and labeled by the Chemical Safety Officer and the Radiation Safety Officer.

All vessels containing radioactive materials must be labeled. Primary waste containers should also be labeled with the radionuclide and the authorized user’s name.

Benchtop work areas should be delineated with warning tape.

All machines and instruments in contact with radioactive material must be labeled.

All radioactive waste containers must be identified with a “Radioactive Waste” label. These are available from the RSO.

Notices to Employees, Emergency Procedures, Operating Procedures and Notices of Violations shall be posted in all radioactive material work areas. License, amendments and copies of F.A.C 64E-5 are on file in Physical Plant, Room 111.

SECURITY

Radioactive material use areas must be secured when the area is left unattended.

Store radiation sources in an RSO approved lab always under control and locked at the end of the workday.

If radioactive materials must be stored in refrigerators or freezers outside of the radiation handling laboratory, the refrigerator or freezer must be locked at all times.

PERSONAL PROTECTION

Wear a full-length laboratory coat when handling unsealed radiation sources. The coat should be buttoned and the sleeves extended to cover the arms. Remove the laboratory coat when leaving the radiation-handling laboratory. Do not place near “street” clothing.

Wear at least one pair of disposable gloves when handling unsealed radioactive materials.

Remove gloves before leaving the work area and dispose of them in the radioactive waste container if the gloves are contaminated, or are suspected to be contaminated.

Check hands and feet with instrument prior to leaving work area.

DOSIMETRY: WORKER RESPONSIBILITIES

Administrative Badging

Workers who use sealed or unsealed sources of radiation may be required to wear personal dosimetry as part of the University’s administrative badging program. Exceptions to this are for personnel who:

use low energy beta emitters, such as H-3, C-14, and S-35

use of I-125 containing “kits”

use and maintenance of Ni-63 sources in gas chromatographs

use of exempt materials

use pure alpha emitters

Exposure reports will be reviewed on a quarterly basis. Any employee whose exposure has exceeded exposure limits shall be moved to the mandatory program.

Mandatory Badging

A whole body dosimeter must be worn by any individual using or assisting in the use of unsealed sources of radioactive materials of any gamma-emitting isotope with gamma ray energy greater than 50 keV or any beta-emitting isotope with maximum beta energy greater than 300 keV. Whole body dosimeters will be exchanged quarterly.

A ring (extremity) dosimeter must worn by any individual using or assisting in the use of unsealed sources of radioactive materials of beta-emitting isotope with maximum beta energy greater than 1000 keV in quantities over 1 millicurie per month. Extremity dosimeters under mandatory badging requirements will be exchanged monthly.

It is the responsibility of a pregnant woman to declare her pregnancy to the RSO if she wishes to have additional measures taken to insure that fetal dose limits are not exceeded. Fetal monitors will be exchanged monthly.

Dosimeter usage:

Wear badge whenever working with radiation sources.

Badge must face outward.

Keep badges at work in designated area away from x-ray producing machines and sources.

Do not wear during medical tests.

Most TLD personal and area dosimeters are exchanged on a quarterly basis except for extremity badges associated with mandatory badging and fetal monitors (exchanged monthly)

Never use another worker’s badge. If badge is lost or damaged, a spare can be issued through the RSO.

Wear whole body badges on the torso, at or above the waist and below the shoulder.

The ring badges should be worn under the glove on the hand that is more likely to receive radiation exposure.

Badges should be stored in an area designated by the RSO. They should be stored with the control badge if possible and protected from moisture and extreme environmental conditions, such as intense heat or light, which may affect their ability to accurately record radiation exposures.

The RSO will change out the badges when required.

Spare badges can be issued to visitors and new hires who need to start work.

Arrangements will be made during training and indoctrination sessions to order permanent badges.

DOSIMETRY: RSO RESPONSIBILITIES

The RSO will arrange with Global Dosimetry to have dosimeters and extremity monitors provided to all workers in the mandatory program and workers not excepted from the administrative program.

Distribute dosimeters and ring monitors to all participating departments.

Review the personnel radiation exposure readings to ensure that they are within the ALARA action levels.

Notify personnel in writing when exposure readings exceed ALARA action levels.

Take action to reduce radiation exposures when necessary.

Maintain lifetime personnel radiation exposure records.

Obtain radiation exposure records from personnel who have worn dosimeters at other institutions.

Send an annual radiation exposure report to current personnel in the mandatory dosimetry program.

CONTAMINATION SURVEYS

Surveys with radiation instruments and wipe surveys must be completed using form RC-14 Radioactive Material Contamination/Wipe Survey Report. These forms must be kept in the laboratory radiation records notebook. Procedures on wipe samples and surveys with radiation detection instruments can be found as a supplement in the laboratory records notebook.

Contamination is considered to be any reading that is three times above background levels. The following are general guidelines for contamination surveys:

The radiation worker will complete a survey with a radiation survey instrument at the end of each day when unsealed radioactive materials have been used.

If the instrument used is incapable of detecting dose rates down to 0.1 millirem, or is incapable of detecting the isotope used (ex. H-3), a wipe survey will be completed for removable contamination at the end of each day of use.

The radiation worker will complete a wipe survey for removable contamination once per week during weeks of use of unsealed radioactive materials. Wipes should cover areas of use, storage, and waste storage.

If contamination is found, the area will be cleaned and resurveyed. Use RC-14 Radioactive Material Contamination/Wipe Survey form to indicate the actions taken. Call the RSO if assistance is needed.

A wipe survey is conducted at least quarterly by the RSO in all rooms or laboratories where unsealed radioactive material is used or stored. If contamination is found, the authorized user will be notified to have the area decontaminated.

LEAK TESTS

Sealed sources not listed on the license as in storage and under control of the RSO are leak tested by the RSO every six months. Samples are taken utilizing a standard 1” wipe or a swab. Samples are brought to the RSO radiation lab and counted on the Ludlum 2929 scaler. A 0.005 μCi Cs-137 standard is used, and all samples are counted for five minutes. Sample readings below the standard count indicate that the sources are not leaking.

Sealed sources listed on the license as in storage and under control of the RSO will be tested prior to transfer to an authorized user for research or teaching purposes.

INVENTORY

Every six months the RSO completes a Semi-annual Inventory of sealed sources during leak tests. This inventory will include sources in storage.

MINOR SPILL

A minor spill is defined as a spill involving:

1. less than 100 micro Curies (0.1 milliCuries, 3.7 MegaBecquerels), and

2. less than a liter, and

3. no personnel contamination

Action to take:

Contain the spill and soak up with absorbent material.

Conduct a wipe test to ensure that the spill has been cleaned up.

Send a report to the RSO using the standard contamination survey form.

MAJOR SPILL

A major spill is defined as a spill involving:

more than 100 microcuries, or

more than a liter, or

any amount of activity which results in personnel contamination

Action to take:

Contain the spill by absorbing as much as possible with absorbent material, such as paper towels.
Notify all persons to leave the area of the spill.
Leave contaminated shoes and clothing in the room where the spill occurred.
Secure the area by locking the door and posting a sign to “KEEP OUT”, or post a guard outside the area where the spill occurred.
Decontaminate any contamination to personnel; immediately wash with soap and/or commercial detergents and recheck; consider clipping fingernails.
If skin is cut, irrigate with running water.
Contact the supervisor of the room where the spill occurred.
Contact the RSO.

0800-1700 Monday - Friday....................823-0071
All other times: (Emergency)..........…......911

Campus Police will contact the Department of Environmental Health & Safety and then proceed to the scene to assist lab personnel in securing the area.

Send the RSO a report of the incident and the actions taken.

EMERGENCIES

The RSO responds immediately to:

personnel contaminated with radiation
major spills of radioactive materials
fire in a radiation-handling laboratory
requests by lab personnel for assistance
reports of lost or stolen radioactive material (The Bureau of Radiation Control will be notified, as described in 64E-5.343, F.A.C.)

Campus police have the home telephone number of the RSO for contact if an emergency occurs after working hours.

Notices to Employees and Emergency Procedures and phone numbers shall be posted in all radioactive material work areas.

WASTE DISPOSAL

Only authorized radiation workers may handle radioactive waste.

Sort the waste by appropriate categories defined by the RSO. These include: dry waste, liquid waste and scintillation vials. All radiation symbols must be defaced before disposal in the dry waste container.

Radioactive waste that also contains chemically hazardous waste must be collected separately from non-chemically hazardous waste streams.

A waste manifest must be filled out prior to the pick up of radiation waste. It is advisable to allow two days for the RSO when requesting a waste pick up.

All waste containers must be properly labeled.

Radioactive waste must not be disposed of in the normal trash. Check the trashcans when you are checking other areas of the laboratory for contamination.

Do not evaporate radioactive waste in fume hoods unless approved by the RSO. Approval requires a trial to determine if any environmental releases and fumehood contamination occurs. All chemicals being evaporated must be known in order to get approval.

Maintain all waste records and RC-13 Isotope Log Inventory forms in the radiation records notebook.

The RSO will bring waste to the radiation storage facility at the Physical Plant and segregate according to type. Short-lived isotopes will be held for decay, and long-lived isotopes will be stored until pick up by a waste broker.

Radioactive waste must not be disposed of in the sink or sewer without permission of the RSO. The following procedures must be used:

Workers must assure that the water-soluble liquid waste does not exceed criteria listed in http://www.ehs.ucf.edu/Radiation/sewerables.pdf

The isotope sink/sewer discharge log must be filled out for each discharge. Keep log in radiation records notebook.

Liquid waste should be discharged only via designated sinks.

Discharge liquid waste slowly to with water running from the faucet to dilute it.

Survey the sink and surrounding work surfaces to confirm that no residual material or contamination remained in the sink or on work surfaces.

Prior to leaving the area, decontaminate all areas or surfaces, if found to be contaminated

RADIATION DETECTORS

The authorized user must provide a radiation detector that is sensitive to the radionuclides they are authorized to possess.

All radiation detectors used in a radiation handling laboratory must be calibrated annually. Check calibration stickers prior to use and only use an instrument if it is within its calibration date.

The RSO oversees the annual calibration of instruments. The authorized user will be notified when calibration is due and is then responsible for sending their detectors to an approved vendor. The RSO has a limited number of detectors that can be loaned to labs for a short period of time while a detector is being calibrated.

Check operation of meter with check source either before each use or once a day.

The radiation worker should always take a background reading, using the lowest setting, and check the batteries of the detector before beginning work. Do not tamper with the internal settings of the detector because doing so will nullify the calibration.

INSPECTIONS

The RSO conducts periodic unannounced inspections of all radiation handling laboratories on campus to ensure adherence to the safety regulations in this manual. A completed RC-16 Laboratory Evaluation form will be sent to the authorized user as notification of the inspection and of violations (if any). If a violation is observed, the RSO will suggest a course of action. The authorized user is expected to correct the violations in a timely manner. The RSO follows up by performing repeat inspections in laboratories where violations have occurred.

GENERAL RADIATION HANDLING PROCEDURES

Do not use radioactive materials for a new procedure until the procedure has been tested by means of a “dry” run.

Conduct all radiation procedures on absorbent paper. Change as necessary.

Do not use mouth suction to pipette radioactive solutions.

Confine all work with volatile or dust-forming radioactive materials to fumehoods approved by the Department of Environmental Health and Safety.

Decontaminate and/or prepare for disposal any glassware or objects that have been in contact with radioactive material.

Remove gloves and wash your hands after handling unsealed radiation sources.

Check hands and feet with radiation detector prior to leaving work area.

No smoking, eating, drinking, or application of cosmetics is allowed in any area where unsealed radioactive materials are handled or stored.

CHAPTER 1: REGULATORY AUTHORITIES

CHAPTER 2: HOW TO BECOME AUTHORIZED TO USE RADIOACTIVE MATERIALS (RAM)

CHAPTER 3: RESPONSIBILITIES OF AUTHORIZED USERS

CHAPTER 4: RESPONSIBILITIES OF RADIATION WORKERS

CHAPTER 5: RADIATION PROCEDURES

CHAPTER 1 REGULATORY AUTHORITIES

CHAPTER 2

HOW TO BECOME AUTHORIZED TO USE

RADIOACTIVE MATERIALS (RAM)

CHAPTER 3

RESPONSIBILITIES OF AUTHORIZED USERS

CHAPTER 4

RESPONSIBILITIES OF RADIATION WORKERS

CHAPTER 5

RADIATION PROCEDURES