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California State University, Long Beach
College of Natural Sciences and Mathematics

Outline

I. Introduction

II. University License

III. Description of the Campus Radiation Safety Program

  1. Role of the University President
  2. Radiation Safety Manual
  3. Radiation Safety Committee
  4. Radiation Safety Officer
  5. Purchasing, Central Receiving, Property and Foundation
  6. Deans, Department Chairpersons etc.
  7. Responsibilities of the Authorized User
  8. Responsibilities of the Radiation Worker

IV. Authorization to Use Ionizing Radiation

  1. Radioactive Materials IRUAs
  2. Radiation Producing Machines: Non-Medical
  3. Radiation Producing Machines: Medical
  4. Conditions Requiring an Amendment to the CSULB License

V. Radioactive Materials Acquisition, Delivery, Custody and Inventory

  1. Acquisition of Radioactive Material
  2. Delivery of Radioactive Material
  3. Custody of Radioactive Material
  4. Inventory of Radioactive Material

VI. Radiation Producing Machines Acquisition, Delivery, Custody and Inv.

VII. Shipment of Radioactive Materials From CSULB

VIII. Security, Labeling and Posting of Radioactive Materials/Areas

  1. Security: Loss and Theft Prevention
  2. Labeling: Containers and Work Areas
  3. Posting: Rooms, Equipment and Storage Units

IX. Radiation Safety Training Requirements

  1. Initial Radiation Safety Training
  2. Continuing Education/Refresher Training

X. Basic Radiation Safety Rules

  1. Keep All Radiation Exposures ALARA
  2. Control and Reduce External Exposure
  3. Eliminate the Potential for Internal Exposure

XI. Evaluation of Internal and External Dose

  1. External Exposure from Radioactive Materials or X-Ray Machines
  2. Internal Exposure from Unsealed Radioactive Materials
  3. Radiation Monitoring and Campus Standards

XII. Radiation Safety Program Audits

XIII. Calibration of Counting/Survey Equipment

  1. Portable Equipment
  2. Beta or Gamma Counters/Spectrometers

XIV. Disposal of Radioactive Waste

  1. Collection and Storage Areas
  2. Radioactive Waste Types

XV. Gas Chromatograph Foils and Sealed Sources of Radiation

XVI. Radioactive Materials Emergencies

  1. Minor Spills of Radioactive Materials
  2. Major Radioactive Spills or Contamination Events
  3. Fires and/or Injuries Involving Radioactive Materials

XVII. APPENDIX

  • Radioactive Materials Program Audit Form
  • Minimum Training for Persons in Radioisotope Areas (MEMO 10)
  • Radiation Dosimetry Program
  • How To Do A Documented Contamination Survey
  • Radiation Producing Machine Requirements (X-Ray & Electron Microscopes)
  • Suggested Reading List

Radiation Safety Manual

Draft version, pending approval by the State of California Radiologic Health Branch

NOTE: In case of emergency, contact the Radiation Safety Office (x55623 during working hours) or University Police (9-1-1, 24 hrs/day)

I. Introduction

The California State Department of Health Services, Radiologic Health Branch (RHB) controls the quantities and use of radioactive materials and radiation producing machines in this State. They have issued a "Broad Scope B" license to this campus which grants the California State University, Long Beach (CSULB) Radiation Safety Committee (RSC) the authority to possess radioisotopes and issue specific radioisotope-use permits called Ionizing Radiation Use Authorizations (IRUAs) to qualified CSULB faculty and staff. Persons granted such authorizations are termed "Authorized Users" or simply "Users".

This Radiation Safety Manual has been established to inform both the RHB and CSULB personnel of campus policies controlling sources of ionizing radiation, and requirements regarding IRUA acquisition and retention. Possession of a valid IRUA is a privilege. Any single IRUA holder's actions can effect the entire CSULB license. For that reason, strict adherence to the provisions of this Manual and the User's IRUA is imperative.

The purpose of the Radiation Safety Program is to ensure that radioactive materials and machines capable of producing ionizing radiation are utilized in a manner which will protect health, eliminate danger to life and property and comply with relevant State and Federal regulations.

II. University License

The University has been issued a "Broad Scope B" license from the California Department of Health Services, Radiologic Health Branch (RHB). Copies of this license are available for inspection at the CSULB Radiation Safety Office.

III. Description of the Campus Radiation Safety Program

A. Role of the University President

The State Licensing Agency considers the President of CSULB ultimately responsible for the safe use of all regulated radioactive materials and radiation-producing machines on campus. The president has the power to appoint members of the Radiation Safety Committee (RSC). The president may delegate functional responsibility to a qualified manager/administrator on campus and has currently delegated this responsibility to the Dean of the College of Natural Sciences and Mathematics (CNSM).

B. Radiation Safety Manual

The Radiation Safety Manual serves as a guide for individuals using or having responsibility for the use of radiation sources, and contains the campus policy, organization, operating procedures and standards for the Radiation Safety program. The Manual addresses most of the conditions stipulated in the University's license for the use of radioactive materials. The applicable governmental regulations are found in the California Code of Regulations Title 17 (17CCR) and in the Code of Federal Regulations Title 10 part 20. The Manual is part of the campus radioactive materials license and as such must be strictly followed. Both the regulations and the Campus License are available for review in the Radiation Safety Office.

Each Authorized User of radioisotopes will be assigned at least 1 copy of this Radiation Safety Manual at the time her or his initial Ionizing Radiation Use Authorization (IRUA) is approved. This official copy shall be kept on-campus for reference and training purposes. The appropriate campus administrators will also receive a copy.

C. Radiation Safety Committee (RSC)

The RSC is responsible for advising the President or designee(s) on all matters related to radiation protection; reviewing and subsequently approving/rejecting proposed uses of radiation and radionuclides; and generally ensuring that the Radiation Safety Program is effective. The RSC may choose to exclude from regulation some "exempt" or "General License" sources of radiation. The RSC is composed of Authorized Users, a CSULB administrative representative the RSO and/or alternate RSO. A majority vote is required in order to approve any IRUA, thus ensuring that the type and quantity of radionuclides requested, the proposed use, and the experience of the personnel involved adequately comply with CSULB standards for radiation protection. The RSC shall meet at least quarterly to review the activities of the Radiation Safety Program and to consider other related matters. Special situations may warrant additional RSC activity e.g. new User applications, etc. A quorum shall be present at all meetings, consisting of a majority of the membership, and will include the RSO or her/his designated alternate.

D. Radiation Safety Officer (RSO)

The State requires that the RSO and alternate RSO be radiation safety professionals. They are specifically named on the University license. The alternate RSO is specifically authorized to perform all RSO duties. The RSO and alternate are assigned responsibility, generally subject to review and approval by the RSC, for control of applicable campus activities, monitoring of radiation and contamination levels, and providing services in radiation control in conformity with government regulation and the policies and standards set forth in this manual. The RSO may delegate some tasks to appropriately trained individuals.

  1. The RSO is responsible for all aspects of radiation control on the campus. The RSO is a member of the RSC and carries out the directives of the Committee, refers matters to the committee for review and approval, and reports to the committee on the overall status of the radiation protection program. Each application for an IRUA or amendment thereto is reviewed by the RSO and either handled directly or referred to the Committee for further consideration.
  2. The RSO is responsible for the review of campus compliance with State and campus policies on radiation protection and for informing the RSC and/or President/designee on matters related to radiation safety as appropriate.
  3. The RSO is empowered to stop any use of any source of radiation on the CSULB campus, and impound any materials/equipment involved when she/he determines that a significant breach of safety or of CSULB procedures or license conditions is taking place. RSO actions are subsequently open to review by the RSC.

E. Purchasing, Central Receiving, Property and Foundation

All persons must obtain RSO approval prior to bringing any radiation source onto campus, including donated items. Orders for radioactive materials or radiation producing machines must bear the signature of the RSO, and the words "Radioactive" or "X-Ray" as appropriate. The Purchasing Department, Central Receiving, Property Office and Foundation Office are conduits for the acquisition, through established procedures, of most radioactive materials and equipment capable of producing ionizing radiation. They must ensure that RSO approval has been obtained prior to processing any transactions involving the above items. The RSO will determine whether the person requisitioning or accepting any radioactive material or radiation producing equipment is authorized to possess and use it. See section V. "Radioactive Materials Acquisition, Delivery, Custody and Inventory" and VI. "Radiation Producing Machines Acquisition, Delivery, Custody and Inventory" for additional information.

F. Deans, Department Chairpersons, etc.

Deans and/or Department Chairpersons must review each IRUA with respect to proposed personnel, locations and uses of radionuclides and radiation machines within their jurisdiction. Department approval of the IRUA or the acquisition/use of an x-ray unit or electron microscope signifies that the department will provide the resources necessary to control hazards, and will establish departmental policies as necessary to support compliance with applicable campus and governmental standards and regulations. IRUA applicants must obtain the signature of their appropriate Department Chairperson(s) and/or Dean in order to be issued an IRUA.

G. Responsibilities of the Authorized User

Each Authorized User is personally responsible for compliance with campus and governmental regulations as they pertain to her/his authorized use of ionizing radiation. Specific responsibilities include:

  1. Notifying the Radiation Safety Office, and/or University Police of the loss or theft of a radiation source, or unsafe conditions beyond the control of the user, e.g. gross contamination, excessive exposure, suspected ingestion, etc.
  2. Obtaining RSO approval in writing BEFORE acquiring radioactive materials, gas chromatographs with electron capture detectors, liquid scintillation counters or any other device containing a radiation source (e.g. moisture detector, thickness gauge etc.).
  3. Keeping and/or submitting required records for inspection at reasonable times by the RSO or government inspectors. These records will include:
    1. Receipt and disposal of radionuclides.
    2. Select surveys of laboratories and workplaces, including radiation and/or contamination levels.
    3. Training records for personnel engaged in radiation work under the responsible Users' supervision, with training for specific laboratory procedures documented as necessary.
  4. Ensuring that all personnel who frequent areas under her or his supervision receive the appropriate level of instruction in basic radiation safety (see "Minimum Training" policy in Appendix for relevant topics).
  5. Ensuring that radioisotope use and storage is limited to locations, protocols, nuclides, chemical/physical forms and amounts listed on the IRUA.
  6. Placing and maintaining required warning signs and labels as appropriate on doors, refrigerators, freezers, incubators, equipment, tools, benches, waste containers etc.
  7. Enforcing the appropriate use of protective clothing and equipment, survey meters, and dosimeters as specified in this Manual or by the RSO/RSC.
  8. Preparing radioactive wastes for disposal in accordance with approved procedures, properly labeling the waste and filling out waste logs as appropriate. See Section VIII. B. "Labeling" and Section XIV. "Disposal of Radioactive Waste" for additional information.

H. Responsibilities of the Radiation Worker

Each person who works with a source of ionizing radiation is responsible for keeping radiation exposures to herself/himself and others "As Low As Reasonably Achievable" (ALARA); for knowing and observing all appropriate radiation safety precautions; for working within the provisions of the IRUA; and for informing the Responsible User or RSO of any unsafe conditions.

IV. Authorization to Use Ionizing Radiation

A. Radioactive Materials IRUAs

1. Applications for Research, Classroom, Animal and Human Use:

a) Research Use

Applications requesting permission to use radioactive materials for research purposes shall be submitted to the RSO and RSC well in advance of the anticipated date of use. Research includes User projects, directed student projects, graduate projects, etc.

b) Classroom Use

Applications requesting permission to use radioactive materials for teaching or demonstration in academic courses must be submitted to the RSC and RSO well in advance of the anticipated date of classroom radioisotope use. Special procedures may be required due to security and/or multiple use problems associated with most teaching areas.

c) Animal Use

Applicants requesting permission to administer radioactive materials to animals should consider the following:

  1. Animals administered radioactive materials shall be housed separately from other animals. Aquaria, cages etc. shall be labeled with appropriate radiation warning signs. Information on the label shall include the name of the person responsible for the experiment, the isotope and quantity, and date of administration. Users who plan to work with live vertebrates should submit the appropriate application to the CSULB Animal Welfare Board well in advance of their intended start date.
  2. Radioactive excreta, animal carcasses and tissues, contaminated cage bedding, etc., must be handled as "Animal Waste" in accordance with current CSULB radioactive waste disposal procedures, and with any additional stipulations from the RSO/RSC.
  3. Users are responsible for ensuring that animal caretakers and custodians are aware of potential hazards and are adequately trained and supervised.
d) Human Use

The administration of radioisotopes, internally or externally, to humans is not permitted on this campus. The Student Health Center is the only campus entity authorized to administer ionizing radiation (in the form of diagnostic x-rays) to humans.

2. Procedure for Obtaining a Radioactive Materials Authorization (IRUA):

a) Submittal of Application

In order to become an Authorized User for projects involving the receipt, possession and/or use of CSULB-License controlled radioactive materials, an "Application for Ionizing Radiation Use Authorization" and a "Statement of Training and Experience" form must be submitted to the RSC via the RSO. IRUAs are granted only to University or Foundation employees and occasionally volunteer or adjunct employees. The applicant must have accrued a minimum of 20 hours of training and/or experience in radiation safety and safe handling techniques. An IRUA cannot be transferred and is required without regard as to whether the items are procured by purchase, loan, gift or previous ownership. IRUA application packets are available in the Radiation Safety Office.

b) IRUA Application Review Process

The RSO first reviews all applications to ensure that the appropriate safety issued have been adequately addressed. The following key parameters will be considered by the RSO and RSC:

  1. applicant training and experience;
  2. training and experience of project personnel;
  3. the nature of the requested facility(ies);
  4. adjacent facility uses;
  5. radiation hazards and chemical toxicity of requested materials;
  6. amount and concentration of radioactive materials;
  7. past radiation safety findings;
  8. input from responsible interested parties;
  9. frequency of use.
c) Signature and Distribution Requirements

If the RSC approves the IRUA application, the IRUA document is then sent to the responsible User for her/his signature, which verifies that she/he will abide by the requirements set forth in the IRUA. The signatures of the Department Chair and the Chair of the RSC must be obtained, after which the IRUA is signed by the RSO. An IRUA for radioactive materials is typically approved for a period of approximately one year. Copies of the completed IRUA are distributed as follows:

  1. Original - retained by the RSO.
  2. Copy 1 - issued to the Responsible User.
  3. Copy 2 - forwarded to the Responsible User's department.

3. Procedure for IRUA Renewal:

  1. Renewal requests must be made through the RSO. The RSO is responsible for assembling any data and documents needed to ensure an adequate review of the request by the RSC. IRUAs must be renewed if:
    1. work with unsealed radioactive materials is to continue; or
    2. any unsealed radioactive materials are to remain in possession of the User.
  2. Issues considered by the RSO/RSC during the review process will include the following:
    1. changes in the scope, location or procedures of the project;
    2. past compliance with pertinent regulations; and
    3. changes in the type or quantity of radioactive materials authorized.

4. Procedure for Amending an IRUA:

Proposed changes in use locations, radionuclides, etc. require an IRUA amendment. Requests to amend an IRUA must be submitted well in advance to the RSO, who will review the request or forward it to the Department Chair or RSC for review if necessary. Changes in use-location usually require approval from the appropriate administrator.

5. Procedure for Terminating an IRUA (Closure):

  1. An IRUA will expire if not renewed, and may be terminated prior to the stated expiration date if the responsible User is found to be willfully or negligently in violation of the University regulations or governmental regulations. Upon termination, all radioactive work must stop and all radioactive materials are subject to impoundment by the RSO. RSO action is subject to review and modification by the RSC. The IRUA will normally be terminated prior to the expiration date upon completion of the Users' need for radioisotopes.
  2. A User terminating her/his IRUA must, with the approval of the RSO, ensure that all unused radioactive material is transferred to another active IRUA, placed in appropriate storage, or disposed of as radioactive waste. The User must ensure the removal of all radioactive contamination on surfaces/equipment in the authorized area(s), and submit to the RSO a detailed radiation survey indicating that all areas listed on the User's IRUA are free from contamination. The User must then remove all warning signs, labels etc., after which the RSO may declare an "uncontrolled release" of the area(s), meaning the area(s) are "unrestricted" and no longer under the jurisdiction of the Radiation Safety Program.

B. Radiation Producing Machines: Non-Medical

The CSULB RSC usually issues special authorizations to the primary Users of non-cabinet type x-ray machines; please see the "Radiation Producing Machines" supplement in the Appendix for details. Written authorizations are not issued to the Users of electron microscopes. The RSO registers each operable electron microscope and radiation producing machine with the State RHB as required. These devices are regulated by the RHB but do not constitute part of the campus Radioactive Materials License.

C. Radiation Producing Machines: Medical

All issues of radiation safety and regulatory compliance within the Student Health Center are managed by the facility's Director; assistance/support from the RSO/RSC is available upon request. These devices are regulated by the RHB but do not constitute part of the campus Radioactive Materials License.

D. Conditions Requiring an Amendment to the CSULB License

Proposals for the use of radioactive materials involving any of the three conditions listed below will require a formal amendment from the State RHB. A written justification must be submitted to the RHB and a detailed safety protocol may also be required.

  1. Use of radionuclides not specifically included in the campus license.
  2. Quantities of radionuclides in excess of the campus license limits.
  3. Use of CSULB-owned radioactive material at off-campus locations.

The license amendment must be obtained from the RHB prior to acquisition of the material or implementation of the new procedure. Since this amendment process typically takes several months, Users are encouraged to contact the RSO well in advance of the need.

V. Radioactive Materials Acquisition, Delivery, Custody and Inventory

A. Acquisition of Radioactive Material

  1. Each shipment of radioactive materials to CSULB must be approved by the RSO. The RSO approval is contingent upon the following:
    1. the requested radionuclide and form is authorized by the User's IRUA;
    2. the amount requisitioned, when added to the User's current inventory does not exceed the total authorized by the IRUA or the University license.
  2. All RHB-regulated radioactive materials brought on campus (regardless of funding source) must be identified and controlled in accordance with the provisions listed below. This includes the receipt of low-level radiolabeled materials/samples sent from off-campus. All orders or other requests for radioactive materials should include the following information:
    1. the identity of the shipping party (e.g. company or institution);
    2. the identity of radionuclide(s), and the amount in appropriate units (mCi, Ci, or Bq.);
    3. the name of the CSULB Authorized User making the request;
    4. the chemical and physical form of the radioactive material; and
    5. an order or requisition number.
  3. The Purchasing Department or Property Office shall alert the RSO of requests to purchase, or have delivered, radioactive materials that have not been approved by the RSO. The RSO usually indicates approval by signing and dating the order form or "Proposed Acceptance of Gifts" form.

B. Delivery of Radioactive Material

The Receiving Department, delivery personnel, and/or the CSULB recipient shall notify the Radiation Safety Office of all radioactive material deliveries. Custody of the radioactive materials may not be formally transferred to the responsible User until the RSO or trained designee has executed the current radioactive item receipt procedure as required by law.

C. Custody of Radioactive Material

After an incoming radioisotope shipment is processed following Radiation Safety procedures, the radioactive material is transferred to the custody of the User, who then assumes complete responsibility for the material. She/he shall be responsible for the proper storage, labeling, inventory accounting, use, waste management etc. of the material. Users who anticipate permanent or extended absence from the University are expected to notify the RSO in advance of departure. An alternate responsible party should be designated and the radioisotopes secured in place or transferred to the custody of the RSO.

D. Inventory of Radioactive Materia

The RSO shall be responsible for keeping master inventory records of all licensed radioactive materials. The RSO shall send all Users a form, "Summary of Inventory of Sealed and Unsealed Sources" four times per year, to be completed and returned in a timely fashion.

VI. Radiation-producing Machines (X-ray Units and Electron Microscopes) Acquisition, Delivery, Custody and Inventory

Departments or individuals considering the acquisition of a radiation-producing machine, whether it be the receipt of a donated item, a loan or a purchase, shall obtain the approval of the RSO prior to bringing the item on-campus. Failure to register the machine and establish appropriate safety measures is a violation of State law. Please see the "Radiation Producing Machine Requirements" supplement in the Appendix section of this Manual.

VII. Shipment of Radioactive Materials from CSULB

Shipments or travel with radioactive materials (such as radiolabeled tissue samples or radioisotope stocks) to and from CSULB must conform to pertinent license conditions and the appropriate State and Federal transportation regulations. RSO approval must be obtained prior to any off-campus shipment of such materials from CSULB in order to insure compliance with these regulations. The recipient of CSULB-shipped radioactive materials must hold a valid radioactive materials license that permits receipt of same. Approval by the RSO/designee at the receiving institution is required prior to shipment.

VIII. Security, Labeling and Posting of Radioactive Materials/Area

A. Security: Loss and Theft Prevention

Regulated radioactive materials shall be stored in a manner that prevents unauthorized removal. Users and program personnel are required to maintain oversight of the radioactive materials, ensure that radioactive materials are secure from theft, and prevent access to radioisotope areas by unauthorized persons e.g. lock doors of areas not under the oversight of a qualified person etc.

B. Labeling: Containers and Work Areas

All containers holding radioactive materials for storage, processing or use, shall be conspicuously labeled with the standard radioactive material symbol. Labels should include the identity of the User or lab worker, radioisotope, maximum activity in microcuries, millicuries or Bequerels, and the date. Containers of improperly labeled radioactive materials are subject to impoundment by the RSO. Contaminated or potentially contaminated equipment dedicated to radioisotope use must also bear caution labels as described above.

C. Posting: Rooms, Equipment and Storage Units

  1. Radioactive Material: All rooms, refrigerators, hoods, and equipment in which radioactive materials are in use or stored shall be posted with the standard radioactive material symbol. Radioactive materials shall not be transferred nor used in an unauthorized area without specific approval of the RSO and subsequent appropriate posting. Radiation areas (>5mR or 0.05mSv/hr ) must also be properly posted.
  2. Notice to Employees: State Form RH 2364 "Notice to Employees" is permanently and conspicuously posted on the official bulletin board on the 100 level of PH2. Users and workers should be familiar with its content.

IX. Radiation Safety Training Requirements

A. Initial Radiation Safety Training

Authorized Users are responsible for ensuring that adequate instruction in basic radiation safety is given to every employee or student who may be exposed to ionizing radiation, or have contact with potentially contaminated surfaces originating from the User's activities. Training issues pertaining to the protection of oneself and others are especially important. Most radiation safety training must be DOCUMENTED; standard documentation forms are available from the Radiation Safety Office. A handout summarizing the minimum training required for radiation workers as well as for persons who frequent radiation/radioisotope areas is included in the Appendix section of this manual. A knowledgeable escort may be provided in lieu of training for the occasional visitor. The RSO will assist in basic radiation safety training by offering periodic training sessions. An abbreviated version of the Radiation Safety Manual is available for issue to all project personnel.

B. Continuing Education/Refresher Training

  1. Project Personnel: Authorized Users are responsible for both project-specific and general radiation safety training for persons affected by their program. Users are also responsible for implementing, and communicating to all appropriate personnel, any new policies or procedures issued by the Radiation Safety Office.
  2. Authorized Users: Authorized Users are required to personally participate in two hours of refresher radiation safety training activity per year. This training may be either live, videotaped, or a written exercise etc. and will be coordinated by the RSO and conducted by technical experts, qualified researchers, administrative representatives, the RSO or representatives from regulatory agencies. Topics of instruction include, but are not limited to the following: RSO program audit reports, radioactive waste, regulatory requirement updates, biological effects, radiation physics, environmental issues, ALARA techniques, radiation detection equipment, recordkeeping, and training tips for project workers.

X. Basic Radiation Safety Rule

A. Keep All Radiation Exposures As Low As Reasonably Achievable (ALARA)

B. Control and Reduce External Exposure by the Following:

Design and conduct all operations with radioactive materials to provide the maximum protection of both personnel and laboratory surfaces. Prior to working with radioactive material, estimate the potential radiation dose by measuring the highest radiation rate and factoring in the expected time of exposure. External radiation exposure from a given radioactive source is controlled by keeping three rules in mind: TIME, DISTANCE and SHIELDING.

  1. Decreasing the TIME of exposure decreases the radiation dose proportionately. Practicing "dry runs" with non-radioactive material prior to actually working with radioisotopes will increase the worker's efficiency and give a good idea of the expected exposure time.
  2. Increasing the DISTANCE from the source is frequently the most effective and economical means to reduce radiation exposure from gamma rays and other highly penetrating radiation. The radiation field varies inversely with the square of the distance. For this reason, tongs or other long-handled tools should be used for manipulating radionuclide preparations emitting significant levels of radiation. Highly energetic radioactive materials should never be picked up with the fingers; the use of short forceps considerably reduces exposure. Placing notebooks and other reference materials out of the high exposure area will also significantly reduce exposure.
  3. SHIELDING the source of radiation will be necessary when exposures cannot be reduced to minimal levels by simply increasing working distance and decreasing exposure time. Shielding is accomplished by putting appropriate materials between you and the radiation source:
    1. Gamma radiation is best shielded by using appropriate amounts of dense materials, typically lead bricks, lead sheets, leaded glass, etc; however, steel, glass or even water can provide some shielding.
    2. Beta radiation is more easily shielded. A few millimeters of solid material is sufficient to totally absorb most commonly encountered beta radiations. High energy 32P beta emissions can produce penetrating x-rays called Bremsstrahlung when shielded by thin lead or steel. Less dense materials such as plastic or glass should be used for shielding 32P whenever possible. When working with energetic beta emitters, care must be taken to avoid exposing hands above open containers where the dose rate can be rems (or sieverts) per hour for commonly used quantities of beta emitters such as 32P.

C. Eliminate the Potential for Internal Exposure:

Incorporation of radioactive material into the body by inhalation, skin absorption, or ingestion is easily prevented by following the radiation protection rules listed below. Inhalation of radioactive material can be prevented by using a properly functioning fume hood when handling volatile or aerosolized radioisotope solutions, or when handling large quantities of non-volatile, unsealed radioactive materials. Follow the standard radiation protection practice guidelines as appropriate to preclude ingestion, or absorption:

  1. Keep the appropriate survey meter ON when using radioisotopes other than 3H; frequently check gloves, work areas, equipment etc. for contamination. Turn switch to "bat" to make sure the battery is good, then check meter function with a radiation source. Personal dosimeters may be issued to quantify exposure when higher energy radiation sources are used. Orient dosimeters to receive the maximum dose you are exposed to during the procedure.
  2. Wear lab coats and impermeable gloves when working with radioactive material. Avoid exposure from contamination by changing gloves as frequently as needed, and never wearing contaminated labcoats etc. Additional protective equipment and/or garments, commensurate with the hazard potential, will be required by the RSO/RSC as necessary.
  3. Wear fully enclosed chemical splash goggles if splash to the eye is possible when working with radioactive liquids.
  4. Keep radioactive solutions and waste in capped or otherwise sealed containers when not in immediate use.
  5. Work with radioactive material in a properly operating fume hood when necessary.
  6. Store and transport containers of radioactive solutions in trays or buckets.
  7. Line trays and working surfaces with absorbent paper as appropriate. Absorbent "benchcote" paper with plastic backing is best; place absorbent side UP!
  8. Clearly label containers of radioactive material and post all radioisotope use/storage areas with the standard radiation warnings. See Section VII. (4.). Any location where a dose of 5 mR/hr could be received at a distance of 30 cm from the radiation source must be posted as "Caution - Radiation Area" as well as "Caution - Radioactive Materials". Radiation Safety will provide pre-printed caution labels upon request.
  9. Conduct work with radioactive materials in accordance with the User's IRUA, and with the appropriate supplemental written radiation safety and operating procedures.
  10. Perform "dry runs" of new procedures with non-radioactive items before using isotope.
  11. Survey work areas after handling radioactive materials. Keep records of such surveys as required (see section XI. C., "Radiation Monitoring and Campus Standards").
  12. Clean up spills promptly.
  13. Do not eat, drink, smoke, store food/drink/tobacco products, or apply or store cosmetics in areas where unsealed radioactive materials are used or stored. Wash hands thoroughly after working with radioactive materials even when gloves were worn.
  14. Do not pipette by mouth.

XI. Evaluation of Internal and External Dose

A. External Exposure from Radioactive Materials or X-Ray Machines

  1. Radiation Safety Office personnel will monitor occupational exposures to radiation, and issue and require the use of individual monitoring devices in accordance with 10 CFR Part 20, Section 20.1502(a).
  2. Personnel exposure data will be a part of the permanent records of the RSO. All radiation workers have access to her/his own dosimetry records and the records of their co-workers. Dosimetry reports will be posted for review in the Radiation Safety Office. Badged personnel are encouraged to review their exposure and initial these reports. Any exposure over 60 millirems (0.6 mSv) will be reported in writing to both the exposed individual and the Authorized User. Upon request of any employee or student, the RSO will provide a report summarizing his/her exposure to radiation as shown in the records. These reports may also be provided to other employers. Additionally, in any case where exposure of an individual to radiation must be reported to the State Radiologic Health Board pursuant to regulations, the RSO will notify the individual in writing as to the nature and extent of the exposure.

B. Internal Exposure from Unsealed Radioactive Materials

1. Bioassay Policy, General:

Bioassays are tests designed to help quantify the dose received from ingested, inhaled or absorbed radioactive material. Radiation Safety personnel will monitor known or suspected occupational intakes of radioactive material by, and assess the committed effective dose equivalent to, individuals who may have exceeded or are likely to exceed the limits specified for radiation workers {10 CFR Part 20, Section 20.1502(b)}. Suitable and timely measurements used for determination of such internal exposures shall be performed as specified by law (Section 20.1204). Bioassays may also be performed upon request for any individual. Most bioassays involve analyzing urine specimens for radioisotope content. Radioiodine bioassays measure thyroid uptake.

2. Bioassay Policy, Radioiodine:

Any individual contemplating the use of 125I must comply with the following bioassay procedure and pertinent instructions.

a) Types of Radioiodine Bioassays
  1. Operational Bioassays: Operational bioassays are typically performed at the beginning of select operations to determine if intake of radioactive materials has occurred due to the use of new processes or equipment. Radiation Safety personnel/Committee members will evaluate the potential for intake and determine when operational bioassays are appropriate. The results of the operational bioassays will be used in evaluating the requirements for future bioassay requirements.
  2. Confirmatory bioassays: Confirmatory bioassays may be voluntarily performed, or required at the discretion of Radiation Safety, to verify that radiation safety control measures are keeping internal doses well below the levels where bioassays would be required by NRC/California regulations. Confirmatory bioassays are applicable for individuals using 5 mCi or 185 MBq or less (0.1 mCi or 3.7 MBq for pregnant women and minors) of 125I in a volatile form, or 10 mCi or 370 MBq (5 mCi or 185 MBq for pregnant women and minors) of 125I in a nonvolatile form.
  3. Routine bioassays: Routine bioassays are performed in accordance with regulatory requirements to assess intakes of radioactive materials and, as appropriate, to calculate internal doses. Routine bioassays shall be performed within 72 hours of any individual using in excess of 5 mCi or 185 MBq (0.5 mCi or 18.5 MBq for pregnant women and minors) of 125I in a volatile form, or 10 mCi or 370 MBq (5 mCi or 185 MBq for pregnant women and minors) of 125I in a nonvolatile form.
  4. Diagnostic bioassays: Diagnostic bioassays are performed to characterize an intake of radioactive materials following suspected ingestion or a significant result from a bioassay measurement.
b) Bioassay Documentation and Interpretation

A thyroid bioassay log book is maintained with the following parameters: name, date, amount of 125I handled, quality assurance check, background level, and gross counts. Thyroid burden and dose are calculated as appropriate. A graph has been prepared that indicates microCurie thyroid burden for any given count value. The graph is based on the measured decay of an NIST- traceable source or equivalent.

c) Action Levels
  1. Anyone whose bioassay indicates a thyroid burden of 2 or more nCi (7.4 e-3 KBq) is required to work with Radiation Safety personnel to evaluate the radioiodine handling procedures and discuss possible measures to keep future exposures ALARA.
  2. Anyone with a bioassay measurement above the CSULB Recording Level (an intake leading to a CEDE of 10 millirems or 0.1 mSv) will undergo diagnostic bioassays as appropriate to confirm the finding, further document the event, and facilitate dose calculations.
  3. If the accumulated CEDE during the year reaches 500 millirems or 5.0 mSv (100 millirems or 1.0 mSv for a declared pregnant woman or a minor), an investigation will be conducted to determine if the resulting dose is ALARA.
d) Recordkeeping and Internal Dosimetry

Individual bioassay measurements indicating a thyroid burden of less than 2 nCi (7.4 e-3 KBq) will be entered in the log, but thyroid burden and dose totals need not be calculated. Individual bioassay measurements indicating a thyroid burden at or above the 2 nCi level but below the Recording Level will have the thyroid burden calculated, but dose totals need not be calculated. Individual bioassay measurements where the results are above the Recording Level will have the individual dose totals calculated as appropriate. If the accumulated CEDE during the year is 1 rem (10.0 mSv) or more, the maximum organ CDE will be calculated and documented as part of the worker's lifetime dose.

e) Radioiodine Dose Assessment

In practice the regulatory requirements for 125I-related internal dosimetry primarily involve recordkeeping at this University.

  1. Nearly all bioassays at CSULB are operational or confirmatory bioassays for internal campus administrative purposes.
  2. A review of current and past radioactive materials projects and bioassay data indicates that no individual at CSULB is likely to receive an internal dose that would require bioassays under Federal or State regulations.
f) Equipment

CSULB radioiodine bioassay equipment employs a thin-crystal NaI detector probe. A water-filled Nuclear Associates Economy Model 74-350 neck phantom is used for calibration and quality assurance purposes.

g) Quality Assurance

The CSULB thyroid monitoring equipment operates within the limits stipulated by State and Federal regulations i.e. performs with a p value between 0.1 and 0.9 according to the Chi-square test. A 129I test-source is measured in the neck phantom prior to each bioassay to confirm that the equipment is functioning properly and is in calibration.

C. Radiation Monitoring and Campus Standards

1. Radiation Levels:

Dose to individuals will be controlled in accordance with 10 CFR Part 20, Subparts C, D, F and G. The RSC limits CSULB projects to ensure that doses to personnel are minimal.

2. User Radiation Monitoring Responsibilities:

  1. Users are responsible for ensuring that radioisotope work areas listed on their IRUAs are in compliance with State limits regarding radiation fields and worker exposures, and that all work is performed in accordance with the campus ALARA policy. Surveys and decontamination activities must be performed by qualified persons.
  2. Each User shall have ready access to survey instrument(s) capable of detecting hazardous amounts of the radiation/radioactive materials used in their program. These instruments shall be operational, in calibration, and continuously available. Instrument manuals, efficiency data and replacement batteries are available from the Radiation Safety Office.
  3. Documented radiation level surveys and/or contamination checks as appropriate shall be performed at least quarterly in areas where unsealed radioisotopes are handled/stored. These checks may be performed semiannually after approval from Radiation Safety and if materials are simply being stored.

XII. Radion Safety Program Audits

In order to monitor compliance with safety principles and rules, the RSO/designee shall periodically perform comprehensive audits of Users' radioisotope programs. Audit frequency (two to four times per year) shall be determined by the RSC based on the frequency of use of radioactive materials, past audit findings, radioisotope amount, toxicity, etc. The audits will focus on the issues listed on the sample audit form included in the Appendix of this manual.

XIII. Calibration of Counting/Survey Equipment

A. Portable Equipment

  1. User survey meters must be calibrated at least once per year. A simple meter function-check with a radiation source will be performed by the RSO/designee during routine audits of User programs.
  2. Meters used by Radiation Safety personnel for radiation safety purposes must have been calibrated within the previous 6 months.
  3. Calibration will be performed only by persons specifically licensed to do so.

B. Beta or Gamma Counters/Spectrometers

Beta and Gamma counters used by Radiation Safety staff for radiation safety purposes must be periodically calibrated and maintained through service contracts with qualified vendors, and/or have calibration confirmed through the use of reference sources as appropriate.

XIV. Disposal of Radioactive Waste (Radwaste)

A. Collection and Storage Areas

Central collection and storage areas for radioactive waste are under the exclusive control of Radiation Safety personnel. The RSO/designee will be responsible for packaging/handling of radwaste for off-campus shipment, but individual generators of radwaste must collect, segregate and store their waste as indicated below or as modified as necessary to comply with evolving regulations. The RSO/designee will dispose of radioactive waste in accordance with State and Federal regulations (10 CFR 20 and 17 CCR).

B. Radioactive Waste Types

Each type of waste indicated below represents a unique waste-type. Waste types must not be mixed!! Biohazardous agents must be inactivated (bleach, autoclave etc.) prior to disposal.

  1. Long Half-Life Dry Solid Waste (1/2 life > 90 days, e.g. 3H, 14C, 65Zn, 109Cd etc.): Long-life dry waste must be deposited in properly labeled containers provided by Radiation Safety. Free liquid, toxic material or lead is NOT permitted. The containers are usually lined with yellow polyethylene bags labeled with red radiation warnings. Needles or other "sharps" must be sealed in puncture-resistant containers before placing in the waste drums. The waste containers and/or accompanying waste logs (usually pink) should indicate the identity of the isotope(s), an estimate of amount in microcuries, millicuries, or Bequerels for each isotope, the date the material was placed in the container, and the identity of the person depositing the waste. Non-radioactive waste ("old" non-contaminated benchcote, non-contaminated gloves, paper towels etc.) may not be placed in this waste stream; the volume must be minimized due to extreme disposal costs!
  2. Short Half-Life Dry Solid Waste (1/2 life < 90 days, e.g. 32P, 33P, 35S, 59Fe, 125I): Short-life dry waste must be deposited in properly labeled containers provided by Radiation Safety prior to pick-up. Free liquid, toxic materials or lead is NOT permitted. The containers are usually lined with black, white or clear polyethylene bags which are NOT marked with radiation warnings. Needles or other "sharps" must be sealed in puncture-resistant containers before placing in the waste drums. The waste containers and/or accompanying waste logs (usually yellow) should indicate the identity of the isotope(s), an estimate of amount in microcuries, millicuries, or Bequerels for each isotope, the date the material was placed in the container, and the identity of the person depositing the waste. Radiation labels should be rendered illegible before placing items in the drum (rolled into gloves, defaced with felt marker, etc).
  3. Scintillation Vials: LSC vials should be tightly capped and stored in a well ventilated section of the lab prior to pick-up by Radiation Safety personnel. The vials and/or accompanying waste logs should indicate the identity of the isotope(s), an estimate of amount in microcuries, millicuries, or Bequerels for each isotope, the date the material was placed in the container, and the identity of the person depositing the waste. If waste scintillation fluid is collected in a bottle, it is called ORGANIC WASTE (see below). Do not add aqueous materials, high activity dilutions, counting standards, or any other waste to this container. MAKE SURE THE SCINTILLATION FLUID IS NOT MISTAKENLY ADDED TO THE RADIOACTIVE AQUEOUS WASTE!
  4. Radioactive Aqueous Liquid Waste: NO SCINTILLATION FLUID, ORGANIC WASTE, OR CHLORINATED SOLVENTS ALLOWED! Dilute solutions of alcohols, organic acids and bases are allowed, but the pH should be kept at 7.5 or greater. Ether is not permitted. Containers for collecting, storing, and disposing of aqueous waste should be no larger than necessary and should be unbreakable or placed in a pan/tray, etc., to provide "secondary containment". Containers and/or waste logs should indicate the identity of the isotope(s), an estimate of amount in microcuries, millicuries, or Bequerels for each isotope, the date the material was placed in the container, and the identity of the person depositing the waste. Users may not dispose of this waste through the sewage system, with the exception of glassware rinsewater from "dishwashing" procedures.
  5. Radioactive Organic Waste; 100% Non-Halogenated: NEVER MIX WITH AQUEOUS WASTE! Used LSC cocktail is often the principle material in Organic waste, but acetone, ether or concentrated alcohols may be added. Phenol, chloroform, acetonitrile, methylene chloride etc. are NOT permitted. Store and label in the same manner as aqueous waste. Containers and/or waste logs should indicate the identity of the isotope(s), an estimate of amount in microcuries, millicuries, or Bequerels for each isotope, the date the material was placed in the container, and the identity of the person depositing the waste. In addition, mark "Flammable" as appropriate.
  6. Radioactive Animal Waste (Carcasses, Tissues and Excreta): Users shall provide adequate and approved freezer storage for Animal waste in plastic bags until the RSO has collected and disposed of the waste following current guidelines.

Please note: Permission from the RSO must be obtained consulted prior to generating any waste which does not conform to the above descriptions, such as halogenated liquids, sealed sources, electron capture detectors, contaminated lead, etc., or waste containing significant quantities of hazardous chemicals. The RSO must be notified prior to generating unusually large volumes of waste material. Special procedures may require RSO and RSC approval.

XV. Gas Chromatograph Foils and Sealed Sources of Radiation

Radioactive foils (63Ni, 3H etc. in gas chromatograph electron capture detectors) and sealed sources containing radioactive material in excess of exempt quantities shall be sampled and tested for external contamination and/or leakage, in accordance with 17CCR, Section 30275 (usually every 6 months). Records of the results of such tests will be maintained by the RSO.

Users may not relocate or dispose of a device containing such a radiation source without RSO authorization.

XVI. Radioactive Materials Emergencies

A. Minor Spills of Radioactive Materials

Project personnel can usually address minor spills involving no significant skin contamination or physical injuries by following the decontamination procedures listed below:

  1. Survey the area to determine the level and location of contamination. Note the readings.
  2. Post the area with appropriate temporary warning signs if necessary.
  3. Mark off contaminated areas with caution tape and/or chalk.
  4. Cover areas as appropriate with paper or benchcote to prevent spread of contamination.
  5. Wear protective clothing such as lab coats, protective gloves and shoe covers.
  6. Remove "hot" spots first, working from the perimeter toward the center to prevent spreading contamination. Do not use excessive water since "run-off" or drips may spread contamination. Dispose of the moist contaminated paper towels in the "Dry Solid" waste; log the isotope(s) and amount in the customary manner. If both long and short life nuclides are mixed together in the spill/cleanup, dispose as long life waste.
  7. Take care not to track contamination around. Control traffic and check all persons leaving the spill area for contamination, paying particular attention to hands, and shoe soles.
  8. Isolate and retain any mops, rags, brushes, and wash solutions until these have been monitored and declared free of contamination. These may need to be disposed of as radioactive waste.
  9. For assistance contact the RSO at x55623.

B. Major Radioactive Spills or Contamination Events

A radioactive incident should be considered "major" when it impacts an area not authorized for radioisotope work or cannot be readily cleaned up in a timely fashion by laboratory personnel; or when there is a significant or unknown hazard to individuals from external exposure, or radioactive material inhalation, ingestion, or skin absorption. Prompt response and clean-up will prevent the spread of contamination and reduce the hazards, inconvenience and costs.

Major incidents should be addressed as follows:

  1. Notify the appropriate emergency personnel:
    1. During working hours, notify the RSO at x55623. DO NOT LEAVE A VOICE MAIL MESSAGE AND ASSUME THAT ASSISTANCE WILL BE FORTHCOMING. If the RSO is not available, call 9-1-1 or pick up an emergency phone which will ring directly to University Police.
    2. After working hours, call 9-1-1 or pick up an emergency phone which will ring directly to University Police.
  2. If safe to do so, survey the area to identify contamination, then confine the spill.
    1. Make sure you are wearing a lab coat and protective gloves. Disposable coveralls are recommended. Gloves, coveralls and booties are stored in the PH2 "Safety Cabinet".
    2. If the spill is a liquid, cover the spill with absorbent paper.
    3. If the spill is a dry material, place dampened absorbent material (paper or towels) over the contamination if safe to do so. Be careful to prevent loose contamination from becoming airborne. Trained personnel equipped with respirators may be required.
  3. Minimize the threat of aerosol contamination if appropriate by turning off fans and hoods if possible, and closing the windows and doors. If airborne radioactive material presents an inhalation hazard, leave the area and wait for respirator-equipped personnel to arrive.
  4. Survey shoes, lab coats, hands etc. before leaving the contaminated area. Remove and contain any contaminated clothing.
  5. If skin is contaminated, flush with large quantities of water. Use a catch basin or sink or floor drain when flushing - not the floor/ground if possible.
  6. Measure exposure levels. If the material spilled is causing high external radiation levels, move to an area of low dose rate.
  7. Post warnings and divert traffic around all contaminated or high exposure areas as appropriate.
  8. Begin decontamination as soon as is safely possible. Follow any instructions given by Radiation Safety personnel.
  9. Do not leave the area or return to routine project work until authorized by the RSO.

C. Fires and/or Injuries Involving Radioactive Materials

Call 9-1-1 immediately or pick up an emergency phone which will ring directly to University Police. Be sure to mention the involvement of radioactive materials to the Dispatcher. Ask them to contact the RSO. It is the responsibility of the Dispatcher to notify the responding agency (Fire Department and/or ambulance) of the involvement of radioactive materials. The person reporting the accident (or other knowledgeable persons) should remain near the scene if possible, and assist by providing information as to the location, type, amount of radioactive materials involved etc.

XVII. Appendix - Radiation Safety Addenda

On the following pages are supplemental radiation safety documents. These documents may be copied and are available from the CSULB Radiation Safety Office, x55623. These addenda are included in User Manuals as appropriate and are subject to revision as regulations evolve. Contact Radiation Safety to make sure you have the most current version.

  • Radioactive Materials Program Audit Form
  • Minimum Training for Persons in Radioisotope Areas (MEMO 10)
  • Radiation Dosimetry Program
  • How to Do a Documented Contamination Survey
  • Radiation-producing Machine Requirements (X-Ray Units and Electron Microscopes)
  • Suggested Reading List
  • RadMan.98