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Vanderbilt University Online Radiation Safety Policies & Procedures Manual
Table of Contents

Section 1: Functions and Responsibilities

A. The Radiation Safety Committee (RSC)
 

Charge. The Committee will:

1. Ensure that radioactive material licensed under the broadscope radioactive material license, and ionizing radiation-producing equipment (i.e. x-ray equipment, fluoroscopes, accelerators, etc.) are used safely, and in compliance with State of Tennessee and federal regulations, broadscope license conditions, and certified registrations;
2. Review and approve or disapprove users and uses of licensed material;
3. Review recommendations on ways to maintain individual and collective doses as low as reasonably achievable (ALARA);
4. Review quarterly, a summary of the occupational radiation dose records (ALARA report) of all personnel working with licensed material;
5. Review quarterly all incidents involving licensed materials with respect to cause and subsequent actions taken;
6. Review annually the radiation safety program.

Responsibilities. The Committee shall:

1. Be familiar with all pertinent state regulations, registrations, the license application, the license, and amendments;
2. Review the training and experience of the proposed principal investigators, and the Radiation Safety Officer (RSO) to determine that their qualifications are sufficient to enable the individuals to perform their duties safely and are in accordance with the regulations, registrations, and the license;
3. Review on the basis of safety and approve or deny, consistent with the limitations of the regulations, registrations, the license, and the ALARA philosophy, all requests for authorization to use radioactive material or electrically generated ionizing radiation within the institution;
4. Prescribe special conditions that will be required during a proposed method of use of radioactive material such as requirements for bioassays, physical examinations of users, and special monitoring procedures;
5. Review quarterly the RSO's summary report of the occupational radiation exposure records of all personnel, giving attention to individuals or groups of workers whose occupational exposure appears excessive;
6. Establish a program to ensure that all persons whose duties may require them to work in or frequent areas where radioactive materials are used (e.g., nursing, security, housekeeping, physical plant) are appropriately instructed as required in 1200-2-4-.12 in the State Regulations for Protection Against Radiation (SRPAR);
7. Review at least annually the RSO's summary report of the entire radiation safety program to determine that all activities are being conducted safely, in accordance with state regulations, registrations, and the conditions of the license, and consistent with the ALARA program and philosophy. The review must include an examination of records, reports from the RSO, results of state inspections, written safety procedures, and the adequacy of the management control system;
8. Recommend remedial action to correct any deficiencies identified in the radiation safety program;
9. Maintain written minutes of all Committee meetings, including members in attendance and members absent, discussions, actions, recommendations, decisions, and numerical results of all votes taken;
10. Ensure that the radioactive material license is amended if required prior to any changes in facilities, equipment, policies, procedures, and personnel.

B. Human Subjects Radiation Committee (HSRC)

The HSRC is a subcommittee of the Institutional Review Board (IRB). This committee reviews proposals involving research uses of radioactive material or ionizing radiation-producing devices in or on humans. The HSRC also functions as the Radioactive Drug Research Committee and reviews proposals that qualify under FDA rules for submission to this committee.

C. Vanderbilt Environmental Health and Safety (VEHS)

VEHS will:

1. Order, receive, and deliver radioactive materials;
2. Manage radioactive waste;
3. Perform laboratory audits and surveys;
4. Perform instrument calibration/performance checks;
5. Provide personnel monitoring/bioassay services;
6. Provide radiation safety support for therapeutic applications;
7. Perform inventory/leak test/survey requirements for sealed sources;
8. Provide Radiation Safety Training;
9. Maintain emergency preparedness;
10. Maintain records;
11. Provide advice and consultation to faculty, on matters related to radiation safety;
12. Monitor radiation users for compliance with State and Federal regulations, license conditions, and policies of the Radiation Safety Committee;
13. Inspect accelerators and x-ray machines for compliance with State regulations;
14. Provide administrative support for the RSC;
15. Provide initial review of proposals submitted to the RSC;
16. Prepare and ship all radioactive materials sent to Vanderbilt.

D. Radiation Safety Officer

The Radiation Safety Officer will:

1. Manage the radiation safety program
2. Identify radiation safety problems
3. Initiate, recommend, or provide corrective actions
4. Verify implementation of corrective actions
5. Ensure compliance with regulations
6. Assist the RSC in the performance of its duties
7. Suspend any operation that is found to be a serious threat to health or property
8. Submit plans for new buildings and modifications of existing structures where ionizing radiations are to be used to the Radiation Safety Committee for approval prior to construction or modification

E. Principal Investigator

The Principal Investigator will:

1. Update all changes in the use of radioactive material with VEHS;
2. Ensure proper receipt/storage of radioactive material;
3. Ensure proper use of radioactive material by individuals who meet Vanderbilt's Radiation Safety training requirements;
4. Limit use of radioactive materials to individuals working under their authorization;
5. Ensure appropriate personnel and area monitoring are performed for radioactive material use;
6. Ensure proper disposal of radioactive waste;
7. Ensure all records of inventory, use, disposal, and surveys are maintained;
8. Ensure workers are familiar with radioactive material spill procedures;
9. Notify VEHS when terminating the use of radioactive material for close out surveys/documentation;
10. Encourage and promote As Low As Reasonably Achievable (ALARA) principals;
11. Communication to VEHS of information regarding changes in operational procedures or facilities which might lead to increased personnel exposure or contamination levels in the laboratory or the environment;
12. Ensure compliance with the Radiation Safety Policies and Procedures Manual;
13. Instruction of employees in the use of safety devices and procedures;
14. When Principal Investigators leave the University, they are required to account for and dispose of all radioactive material and effect any necessary decontamination of laboratory facilities. The Principal Investigator's department must assume these responsibilities if the PI leaves before resolving these matters.

To assist in ensuring that these responsibilities are met, the PI may choose to appoint a Radiation Safety contact person for the laboratory who will ensure day-to-day compliance in the laboratories of the approved user. VEHS provides supplemental training for Radiation Safety contacts to help them review documentation requirements and perform area surveys.

F. Radiation Workers:

Radiation Workers will:

1. Work in a manner that will minimize radiation exposure to themselves, fellow workers, and the general public.
2. Conduct surveys, when working with radioactive material, to assure that radiation levels are As Low As Reasonably Achievable (ALARA). Radiation workers are expected to maintain their radiation exposure As Low As Reasonably Achievable (ALARA).
3. Know and adhere to the Radiation Safety Policies and Procedures Manual and any specific radiation safety procedures that are applicable to their work.
4. Have Radiation Safety Training and Orientation documented with VEHS.
5. Report incidents involving contamination of personnel, unconfined spills, theft or loss of radioactive material, and suspected overexposures to VEHS immediately.
6. Be responsible for posting radiation work areas and properly identifying these materials and any contaminated equipment.
7. Be familiar with the characteristics of the radioactive materials they are using.
8. Be responsible for understanding how survey meters work and which survey meters will detect the radiation they are using.
9. Be familiar with radiation survey procedures and are responsible for surveying work areas for contamination periodically and after each radioisotope procedure. They are responsible for surveying hands, body, and clothing for contamination. If radiation workers are contaminated contact VEHS at 322-2057 or 835-4965 and confine the contaminated workers.
10. Be responsible for the proper use and handling of their personnel monitoring badges, for furnishing bioassay samples to VEHS for analysis when requested, and for obtaining periodic thyroid uptake measurements when working with radioiodine.
11. Be responsible for the proper disposal of their radioactive waste and for maintaining records of all disposals.
12. Be familiar with decontamination procedures and are responsible for the cleanup of any contamination that they created.
13.  Wear radiation badges at all times when working with or in the vicinity of sources of ionizing radiation, if a radiation badge has been assigned to them.