VII(a). Radiation Safety Policy & Procedure Manual for Radionuclide Use

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rev 7/2012

Table of Contents

  1. Scope
  2. Introduction
  3. Important Telephone Numbers
  4. Responsibilities
    1. Radiation Safety Committee
    2. Radiation Safety Officer
    3. Assistant Radiation Safety Officer
    4. Licensed Investigator
    5. Individual User
  5. License Requirements
    1. Persons Applying
    2. Permissible Radionuclides
    3. Authorization Procedures
    4. Occupational Exposure
    5. Exposure of the Embryo/Fetus
    6. Exposure of the Public
    7. Laboratory Classifications
    8. Compliance With Regulations
    9. Surveys and Audits
    10. Contamination Limits
    11. Storage Policy
    12. Calibration of Survey Meters
    13. Licensed Investigator Absent Or On Leave
    14. Visitors and Pets in the Radionuclide Laboratories
    15. Prenatal Radiation Exposure
  6. Personnel Monitoring and Training
    1. Training
    2. Personnel Dosimetry
    3. Personnel Exposure Investigation Levels
  7. Procurement And Use Of Radionuclides
    1. Procedures For Procurement
    2. Delivery of Radionuclides
    3. Transfer Of Radionuclides To Other Individual
    4. Transportation Of Radioactive Material
    5. General Requirements And Precautions
    6. Leak Test Requirements For Sealed Sources
    7. Radioactive Material Contained In Equipment
    8. Control Of Exposure To Radiation
  8. Radioactive Waste Disposal
    1. Solid Dry Waste
    2. Liquid Waste
    3. Animal Carcasses And Associated Waste

Appendices

A: Radiological Occurrence Report
B: Control Of Student Exposure To Radiation
C: General Radiation Protection Requirements And Precautions
D: Procedures For Safely Opening Packages Containing Radioactive Materials
E: MHC - Emergency Procedures
F: Safe Use of Radioactive Materials in MHC Research Labs
G: Protocol for Use of Radionuclides
H: Radiation Purchase and Receipt
I: Radiation Safety Training Record
J: ICRP Radionuclide Groups

I. Scope

The policies and procedures contained in this manual apply to all departments, laboratories, and persons using and possessing radioactive material at Mount Holyoke College.

II. Introduction

Ionizing radiation is potentially hazardous unless used with strict adherence to safety rules and procedures. Unlike most other such hazards, the risks of unguarded exposure to ionizing radiation includes the possibility of damage to future generations.[1] Thus, the safety rules which govern all uses of ionizing radiation are concerned with preventing genetic damage as well as protecting the health of the exposed individual. When followed faithfully, these rules limit the exposure of persons who work with radioactive materials to levels far below those that are believed to cause any adverse effects. The rules and procedures set forth in this Manual have one single straightforward purpose; to protect employees and the public against unnecessary and potentially harmful exposure to ionizing radiation.

Four stages of responsibilities are involved in the Radiation Safety Program. All are equally important:

  1. Radiation Safety Committee: This is a group of scientists and administrators appointed by Mount Holyoke College to establish policies and procedures governing the use of ionizing radiation at the College.
  2. Radiation Safety Officer: Responsible for ensuring compliance with established College policies and procedures. He/She also provides a variety of technical services to the College community necessary for achieving and maintaining compliance. In the absence of the Radiation Safety Officer, the Assistant Radiation Safety Officer fulfills the duties of the Radiation Safety Officer.
  3. Licensed Investigators: College faculty members whose training and experience are such that they have been authorized by the Radiation Safety Committee to use ionizing radiation in their research and educational activities. Licensed Investigators are responsible for all aspects of their laboratory's radiation safety compliance program.
  4. Individual Users: Scientists, research personnel, students, technical and other workers engaged in laboratory research, research support, and educational activities which involve actual use or handling of materials and devices producing ionizing radiation. These users work under the immediate supervision of a License Investigator.

1 Information on health risks can be found in U.S. Nuclear Regulatory Commission Regulatory Guide 8.29, Instruction Concerning Risks from Occupational Exposure.

III. Important Telephone Numbers

Campus Police Emergency Ext. 1-911
Emergency from Cell Phone (413)538-2304
Environmental Health & Safety 2529
Jim Tocci RSO (413)323-9571
Janice Hudgings Assistant RSO 2206

IV. Responsibilities

A. Radiation Safety Committee

The Radiation Safety Committee is composed of members appointed by Mount Holyoke College. It has jurisdiction over radiation sources and activities at Mount Holyoke College.

The responsibility and authority of the committee include:

  1. Ensuring the College's compliance with radiation safety regulations promulgated by Federal, State, and Local Agencies.
  2. Establishing policies regarding radiation safety of the Mount Holyoke College Community.
  3. Providing direction and advice to the Radiation Safety Officer on matters regarding radiation safety policy.
  4. Receiving, reviewing, and acting on all applications for the use of radiation and radioactive material in all areas used by Mount Holyoke College personnel.
  5. Issuing usage permits for approved radioactive material activities.
  6. Receiving and reviewing periodic reports from the Radiation Safety Officer on monitoring, contamination and personnel exposure.
  7. Periodically reviewing the overall use of radiation sources at Mount Holyoke College.
  8. Reviewing instances of alleged infraction of use and safety procedures with the Radiation Safety Officer and the responsible individuals.

B. Radiation Safety Officer

The Radiation Safety Officer is the operational representative of the Radiation Safety Committee. He/She is responsible for:

  1. Implementing policy decisions of the Radiation Safety Committee.
  2. Assisting the College in meeting compliance with radiation safety regulations promulgated by Federal, State and Local Agencies.
  3. Coordinating the review of all Protocols by the Radiation Safety Committee.
  4. Issuing reports of non-compliance to P.I.’s. Recommending sanctions to the committee if a violation persists.
  5. General surveillance of all radiation safety activities, including both personnel and environmental monitoring.
  6. Furnishing consulting services to personnel at all levels of responsibility on all aspects of radiation safety.
  7. Implementing procedures for purchasing, receiving and shipping all radioactive materials coming to or leaving Mount Holyoke College.
  8. Surveying all College accelerators, radionuclide laboratories, x-ray machines and other equipment capable of producing ionizing radiations.
  9. Distributing and processing of personnel monitoring devices including film badges. The keeping of records of internal and external personnel exposure, and notifying individuals and their supervisors of excessive exposures, as well as recommending appropriate remedial action. Personal exposure information will be made available upon request by an individual.
  10. Arranging for the calibration of all portable survey instruments at Mount Holyoke College and maintaining the required records.
  11. Instructing users and non-users in proper safety procedures for working with radioactive materials or radiation producing equipment as requested by Licensed Investigators.
  12. Supervision and coordination of the waste disposal program, including the processing, storage and disposal of radioactive waste and the keeping of the required records.
  13. Performing or supervising the leak tests on all sealed sources and maintaining the required records.
  14. Maintaining an inventory of radioactive materials.
  15. Responding to laboratory emergencies involving radiation exposure or contamination.

C. Assistant Radiation Safety Officer

In the absence of the Radiation Safety Officer, the Assistant Radiation Safety Officer fulfills the duties of the Radiation Safety Officer.

D. Licensed Investigator

Licensed Investigators are responsible for insuring that the individual user responsibilities in subsection E are discharged by those under their supervision and are further responsible for:

  1. Adequate planning of experiments and determination of the type and quantity of radiation or radioactive material to be used. This determination will give a good indication of the safety measures that should be employed. Experimental procedures must be well outlined to allow adequate review of safety precautions. Where possible, a cold run using the planned procedures or tracer quantities of radioactive material is recommended to avoid unforeseen safety problems. In any situation where there is an appreciable radioactive hazard, the Radiation Safety Officer should be consulted before proceeding.
  2. Establishing procedures to ensure that exposure to all users working under the Investigator’s supervision and others present in the laboratory are maintained as low as possible, and specifically below the maximum permissible exposures established in 105 CMR 120 as described in Section V subsections D, E and F.
  3. Instructing all users and non-users for whom they are responsible regarding safe techniques and approved radiation safety practices.
  4. Ensuring that you are in the laboratory, or on-campus and your whereabouts known, when radioactive materials is being used in your laboratory. Should use be necessary when you are not on campus, you must make arrangements with another authorized investigator to supervise that use. The Radiation Safety Officer should be informed of that arrangement.
  5. Amending the protocol in a timely manner with the Radiation Safety Officer whenever changes in operational procedures, new techniques, alterations in physical facilities, or when new operations which might lead to personnel exposure are anticipated.
  6. Complying with the regulations governing the use of radioactive materials and radiation producing equipment as established by the Commonwealth of Massachusetts' Department of Public Health, Local regulations, and the Mount Holyoke College Radiation Safety Committee for:
    1. Obtaining approval from the Radiation Safety Committee prior to starting any activities that involve the use of radioactive material.
    2. Using proper procurement and transfer procedures
    3. Posting areas where radionuclides are kept or used, or where radiation fields may exist
    4. Security of radionuclides in their possession from unauthorized use
    5. Recording the receipt, transfer and disposal of radioactive materials in their area. This includes sealed sources, such as ion sources in gas chromatographs and static eliminators. Inventory data shall be submitted to the Radiation Safety Officer when requested
    6. Assuring that all radioactive waste materials are disposed in accordance with all applicable regulations and College procedures
    7. Assuring that appropriate records of radionuclide usage are maintained and reported to the Radiation Safety Officer when requested
    8. Providing adequate and appropriate instrumentation for assessing potential radiation hazards in their area and performing routine surveys of the work area as necessary
    9. Taking steps to prevent the transfer of radioactive materials to unauthorized individuals. This includes the proper disposition of radioactive materials possessed by terminating employees and/or students.
  7. Keeping the stock of stored radioactive materials to a minimum within laboratory areas.
  8. Insuring that service personnel are not permitted to work on equipment, hoods or sinks in radiation areas without first providing specific information.
  9. Complying with proper procedures for terminating employment or terminating an experiment using radioactive materials. The Licensed Investigator must return to the Radiation Safety Officer all radioactive materials, including waste, assigned to him under the license. A final termination survey by the Radiation Safety Officer is also necessary.

E. Individual User

Each individual at Mount Holyoke College who has any contact with radioactive materials or radiation producing equipment, is responsible for:

  1. Following all established practices and procedures designed to maintain his/her exposure to radiation as low as possible, and specifically below the maximum permissible exposure as described in Section V, subsection D and E.
  2. Wearing the prescribed monitoring equipment such as film badges and finger dosimeters in radiation areas. Personnel who work only with pure alpha emitters, or only with pure beta emitters having a maximum energy of less than 0.2 MeV will not be required to wear film badges.
  3. Storing the required monitoring equipment such as film badges and finger dosimeters in the locations prescribed by the Radiation Safety Officer.
  4. Surveying their hands, shoes and body for radioactivity and removing all loose contamination before leaving the laboratory.
  5. Utilizing all appropriate protective measures such as:
    1. Wearing appropriate clothing whenever working with radionuclides, and not wearing shorts, sandals, etc.
    2. Wearing protective clothing whenever working with radionuclides, and not wearing such clothing outside of the laboratory area.
    3. Wearing gloves and respiratory protection when necessary.
    4. Using protective barriers and other shields whenever possible.
    5. Using mechanical devices when appropriate to reduce exposure.
    6. Using pipette filling devices. Never pipette by mouth.
    7. Performing radioactive work within confines of an approved hood or glove box unless serious consideration has indicated the safety of working in the open.
  6. Not eating, drinking, smoking, or applying cosmetics in areas where radioactive materials are present. Refrigerators shall not be used jointly for food, beverages and radioactive materials.
  7. Maintaining good personal hygiene. Do not work with radioactive materials if there is an open or unprotected break in the skin below the elbow. Wash hands and arms thoroughly after working with radioactive materials.
  8. Checking periodically for contamination in the immediate areas where radioactive materials are being used (hoods, benches, etc.). Any minor contamination observed should be decontaminated. Large amounts of activity found must be decontaminated. The Radiation Safety Officer may be contacted for assistance if necessary.
  9. Keeping the laboratory neat and clean. The work area should be free from equipment and materials not required for the immediate procedure. Keep or transport materials in such a manner as to prevent breakage or spillage (double container), and insuring adequate shielding. Keep work surfaces covered with protective material to limit and collect spillage in case of accident.
  10. Label and isolate radioactive waste and equipment, such as glassware, used in laboratories with radioactive materials. Once used for radioactive substances, equipment should not be used for other work and should not be permitted to leave the area until demonstrated to be free of contamination.
  11. Ensuring all contamination is removed from equipment prior to repair by shop personnel or commercial service contractors.
  12. Reporting accidental inhalation, ingestion, or injury involving radioactive materials to the Licensed Investigator and the Radiation Safety Officer, and carrying out their recommended corrective measures. The individual shall cooperate in any and all attempts to evaluate his exposure.
  13. Carrying out decontamination procedures when necessary, and taking the necessary steps to prevent the spread of contamination to other areas.
  14. Prompt compliance with requests from the Radiation Safety Officer concerning body burden measurements, submission of bioassay samples, and scheduling for requested radiation physical examinations.

V. License Requirements

A. Persons Applying

As a matter of College policy, the person applying for authorization should be a faculty member of Mount Holyoke College. At the discretion of the Radiation Safety Committee, non-faculty will be considered on a case by case basis. The Radiation Safety Officer will furnish application forms and necessary information.

B. Permissible Radionuclides

Mount Holyoke College's broad scope license authorizes the use and possession of non-exempt quantities of radioactive material. Other radionuclides may be used after the College's Massachusetts license has been appropriately amended and special approval has been given by the Radiation Safety Committee.

C. Authorization Procedures

The Radiation Safety Committee desires to have a minimum of "red tape" to secure radionuclides, but not all of it can be eliminated. The Licensed Investigator can save time and trouble by following these instructions and by using as much foresight as possible in anticipating his/her needs.

  1. Licensed material shall not be used in or on human beings.
  2. To obtain licensed amounts of any radioactive material for non-human use complete the following steps:
    1. Complete a Protocol form [Appendix VII(a)-G] and return to the Radiation Safety Officer.
    2. Contact the Assistant Radiation Safety Officer and make arrangements to view the Radiation Safety training video.
    3. For Licensed Investigators renewing or amending an existing license, only the Protocol form needs to be submitted for review.
  3. These completed forms are circulated to the Radiation Safety Committee and when approved the Radiation Safety Officer notifies the applicant.
  4. For radionuclides and uses not covered by Mount Holyoke College's license, the Radiation Safety Committee and Massachusetts Department of Public Health must both approve. Application is made on the Mount Holyoke College protocol form.

D. Occupational Exposure

Practices and procedures must be in place to ensure that exposure to radiation is as low as possible, and specifically below the maximum permissible exposure limits established by the Department of Public Health.

  1. Occupational Dose Limits for Adults (105 CMR 120.211)
    An annual limit of whichever is less of:
    1. The total effective dose equivalent (TEDE) being equal to 5 rems (0.05 Sv).
    2. The sum of the deep-dose equivalent and the committed dose equivalent to any individual organ or tissue other than the lens of the eye being equal to 50 rems (0.5 Sv).

      The annual limit to the lens of the eye, to the skin, and to the extremities, are:

      1. An eye dose equivalent of 15 rems (0.15 Sv).
      2. A shallow-dose equivalent of 50 rems (0.5 Sv) to the skin or to any extremity.
  2. Occupational Dose Limits for Minors (105 CMR 120.217)
    The annual occupational dose limits for minors, persons who have not reached the age of 18, are 10 percent of the annual dose limits specified for adult workers.

E. Exposure of the Embryo/Fetus

  1. Dose Limits to an Embryo/Fetus (105 CMR 120.218)

    The dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant worker, is limited to 0.5 rem (5 mSv).

    Every effort must be made to avoid substantial variation above a uniform monthly exposure rate to a declared pregnant woman so as to satisfy the limit above.

The dose to an embryo/fetus shall be taken as the sum of:

  1. The deep-dose equivalent to the declared pregnant woman
  2. The dose to the embryo/fetus from radionuclides in the embryo/fetus and radionuclides in the declared pregnant woman.

If by the time the woman declares pregnancy to Mount Holyoke College, the dose to the embryo/fetus has exceeded 0.45 rem (45 mSv), the College shall be deemed to be in compliance with 150 CMR 120.218(A), if the additional dose to embryo/fetus does not exceed 0.05 rem (0.5 mSv) during the remainder of the pregnancy. Section V.O. describes procedures for declaring a pregnancy.

A declared pregnant woman may not use radioactive material or radiation producing equipment in such a manner that the embryo/fetus could receive a dose in excess of the limits specified in 105 CMR 120.218.

F. Exposure to the Public

  1. Dose Limits for Individual Members of the Public (105 CMR 120.221)

The College shall ensure that:

  1. The total effective dose equivalent (TEDE) to individual members of the public from licensed operations does not exceed 0.1 rem (1 mSv) in a year, exclusive of the dose contribution from the disposal of radioactive material into sanitary sewage in accordance with 105 CMR 120.253.
  2. The dose in any unrestricted area from external sources does not exceed 0.002 rem (0.02 mSv) in any hour.
  3. The total effective dose equivalent (TEDE) to individual members of the public from infrequent exposure to radiation from radiation machines does not exceed 0.5 rem (5mSv).

G. Laboratory Classifications

  1. Unsealed Sources

    Information for Classifying Laboratories
    Radionuclide Survey Frequency Category
    Group
    Low
    Medium
    High
    1 < 10µCi 10µCi to 1mCi > 1mCi
    2 < 1mCi 1mCi to 100mCi > 100mCi
    3 < 100mCi 100mCi to 10Ci > 10Ci
    4 < 10Ci 10Ci to 1000Ci > 1000Ci

    Proportional fractions are to be used for more than one radionuclide.

    Modifying Factors Factors
    Simple storage x 100
    Very simple wet operations (e.g., preparation of aliquots of stock solutions) x 10
    Normal chemical operations (e.g., analysis, simple chemical preparations x 1
    Complex wet operations (e.g., multiple operations, or operations with complex glass apparatus) x 0.1
    Simple dry operations (e.g., manipulation of powders) and work with volatile radioactive compounds x 0.1
    Exposure of non-occupational persons x 0.1
    Dry and dusty operations (e.g., grinding) x 0.01

    The object is to determine how often to survey the laboratory. To do this, multiply the activity range under Low, Medium, and High survey frequency by the appropriate Modifying Factor to construct a new set of mCi ranges for Low, Medium, and High survey frequency.

    Example: A lab in which 10mCi of Group II radionuclide is used in normal chemical operations should be surveyed on a Medium frequency. However, if only simple storage is done, then a Low frequency is adequate (< 1mCi x 100 = < 100mCi new Low range). But if a dry grinding operation is done, a High frequency is required (> 100mCi x 0.01 = > 1mCi new High range). See Appendix VII(a)-J for ICRP Radionuclide Groups.

  2. Sealed Sources
    The Radiation Safety Committee assigns laboratory classifications for sealed sources on a case by case basis. Radioactive material, construction of source container, and proposed uses are examples of items considered in assigning the laboratory classification.

H. Compliance with Regulations

Each Licensed Investigator is responsible for ensuring that all laboratories and personnel under his/her control comply with the applicable Federal, State, and Local regulations; and College policies and procedures. The College's Radiation Safety Officer will provide consultation advice regarding the various regulations, however, the Licensed Investigator is ultimately responsible for all activities. All users and non-users working in a radionuclide laboratory should become familiar with the following:

  1. Commonwealth of Massachusetts, Department of Public Health - Chapter 105 CMR 120.
  2. Mount Holyoke College - Radiation Safety Policy and Procedure Manual.

All the above regulations are maintained in the Environmental Health & Safety Office and are available for review.

Licensed Investigators should also be aware that in addition to items 1 and 2 above, Mount Holyoke College must comply with the following regulations:

  1. U.S. Environmental Protection Agency - Title 40, Code of Federal Regulations.
  2. U.S. Department of Transportation - Title 49, Code of Federal Regulations.
  3. U.S. Department of Labor, OSHA - Title 29, Code of Federal Regulations.

I. Surveys and Audits

Each laboratory using radioactive materials must provide the appropriate radiation detection instruments to enable it to conduct routine surveys for radiation exposure and/or surface contamination. The frequency of these surveys will generally be set by the laboratory classification as follows:

Low . . . . not less than monthly

Medium . not less than weekly

High . . . not less than once per normal working day

The above frequency of routine surveys shall not be considered as fixed. When any survey reveals contamination above the limits specified by the College's policies and procedures, the Radiation Safety Officer shall be notified and the laboratory may be placed into the next higher frequency until it is in compliance with the acceptable limits.  Likewise, laboratories consistently displaying excellent radiation safety practices may be placed in a less frequent schedule by the Radiation Safety Officer. The RSO will also perform routine lab surveys on a regular basis. If there are conditions found in non-compliance, a Radiological Occurrence Report will be issued to the licensed investigator (See Appendix VII(a)-A).

The minimum survey frequency for all laboratories using unsealed radioactive sources is quarterly.

The minimum survey frequency for all laboratories using sealed radioactive sources is semi-annually with the exception of sealed sources declared in storage.

J. Contamination Limits

  1. An individual wipe test should routinely cover approximately 100 - 150 cm2. Ideally, any contamination more that a few DPM above background should be cleaned up; however, a more usual level for beta/gamma at which cleanup is initiated is about 200 DPM. At approximately 1000 DPM a contamination zone should be established until the contamination is removed.
  2. Contamination levels may also be estimated with a survey meter. As a rough rule of thumb, establish a contamination zone if readings are > 100 CPM for Groups 1 and 2 radionuclides and > 1000 CPM for Groups 3 and 4 radionuclides when measured with a thin window GM meter. Of course, this particular instrument will not detect low energy beta emitters such as tritium.
  3. Notify the Radiation Safety Officer if contamination is suspected beyond the designated radioactive material laboratory boundaries.
  4. In all cases notify the Radiation Safety Officer if clean-up is not successful.
  5. You may notify the Radiation Safety Officer at lower levels if you wish assistance in clean-up or if you wish your clean-up results checked.
  6. Clean-up suggestions:
    1. Be sure to wear protective clothing while cleaning (gloves, lab coats, shoe covers, etc.).
    2. Use mild soap or other appropriate cleanser for the material which has been spilled.
    3. Work from the outside of the spill toward the center being careful not to spread the contamination and reduce the "counts" by dilution.
    4. Rewipe after cleaning to check your technique.

K. Storage Policy

  1. The storage of radioactive material in the laboratories shall comply with the following:
    1. Radioactive material shall be kept or stored in a manner that will provide minimum exposure to personnel.
    2. Suitable storage precautions shall be taken against fire, explosion, flooding, or unauthorized removal.

L. Calibration of Survey Meters

Radiation survey meters shall be calibrated annually. This calibration will be done by an approved calibration facility or by the Radiation Safety Officer using NRC approved procedures.

M. Licensed Investigator Absent or On Leave

During an absence from Mount Holyoke College of more than two weeks, a Licensed Investigator shall make arrangements to have another Licensed Investigator be responsible for his/her licensed material if research activities are continued.

The Licensed Investigator should also inform the department head and laboratory staff of the arrangements. The faculty person designated is expected to assume the responsibilities of the licensee to oversee radioactive material use.

N. Visitors and Pets in the Radionuclide Laboratories

Licensed Investigators shall restrict casual traffic through laboratory areas where radioactive materials are used. Common sense and good judgment should be exercised to avoid accidents, especially where the exposure of minors is possible.
Pets are not allowed in laboratories where radioactive materials are used or stored.

O. Prenatal Radiation Exposure

The developing embryo/fetus is considered more sensitive to radiation than an adult. The main concern is embryo/fetus susceptibility to the harmful effects of radiation such as cancer. A woman working with radiation who becomes pregnant has the option of formally declaring her pregnancy to take advantage of lower established dose limits for the embryo/fetus. Commonwealth of Massachusetts regulations require that if a woman formally declares her pregnancy in writing, the embryo/fetus dose from occupational exposure of the mother not exceed 0.5 rem (5 mSv) over the entire pregnancy. (See section V.E. for additional details.) If a woman chooses not to formally declare her pregnancy, the woman and her embryo/fetus continue to be subject to the occupational dose limits that apply to all other radiation workers. Female workers must understand that by not declaring their pregnancy, they assume full responsibility for their decision.

A female worker wishing to formally declare her pregnancy must provide the following information in writing to the chair of the Radiation Safety Committee with a copy to the Radiation Safety Officer:

  1. Date of declaration
  2. Full name
  3. Social Security Number - This is to ensure that the doses are properly logged in the exposure history records.
  4. A statement declaring she is pregnant
  5. An estimated date of conception - The due date minus 9 months is acceptable. This information is required for dose estimate purposes.
  6. Signature

Upon receiving a pregnancy declaration, the Radiation Safety Officer will calculate the dose to the embryo/fetus between conception and the date of declaration. The Radiation Safety Officer, after consultation with the Radiation Safety Committee, will meet with the woman, and her supervisor if applicable, to discuss the risk associated with the radioactive material(s) used, dose received to date, work procedure requirements and restrictions, and monitoring requirements. The Radiation Safety Officer will stay in contact with the woman during her pregnancy with updated information on dose received, and may impose additional restrictions including work with radiation sources.

It is recommended that decision should be made regarding declaring the pregnancy or other actions early in the pregnancy as the embryo/fetus is considered the most sensitive in the first trimester. Prudent practices for limiting prenatal exposure could include:

  1. Reducing exposure by decreasing the amount of time spent in the radiation area, increasing the distance from the radiation source, and using shielding. Extreme care should be exercised when performing experiments or procedures where you might become contaminated. It is also very important to reduce the potential of an ingestion of radioactive materials during pregnancy. Certain radionuclides may cross the placental barrier and concentrate in the fetus.
  2. Requesting reassignment to areas involving less exposure to radiation. If this is not possible, consider discussing a transfer within Mount Holyoke College with the Human Resources Department, or leaving your job.

Additional information can be found in the following documents available on-line and from the Radiation Safety Officer.

U.S. Nuclear Regulatory Commission Regulatory Guide 8.13, Instruction Concerning Prenatal Exposure.

U.S. Nuclear Regulatory Commission Regulatory Guide 8.29, Instruction Concerning Risks from Occupational Exposure.

VI. Personnel Monitoring and Training

A. Training

105 CMR 120.753 requires that each individual likely to receive an occupational dose be given information on the radiation hazards to be experienced, biological effects of radiation, and techniques of radiation protection. The Licensed Investigator is responsible for training the individuals working in his/her laboratory. Refresher training for individuals who will use or be present near licensed radioactive material will be conducted annually. The materials in Appendices D, and F should be reviewed as part of the training. The training record in Appendix I must be completed and a copy sent to the Office of Environmental Health and Safety.

B. Personnel Dosimetry

It is the intent of the Radiation Safety Committee to maintain occupational radiation exposures at a minimum. In order to accomplish this, the following methods of personnel monitoring are employed:

  1. Film Badges
    Except for individuals using soft beta emitters (max. Energy < 0.2 MeV) and pure alpha emitters, everyone directly involved with radioactive materials, or ionizing radiation producing equipment at Mount Holyoke College facilities may be required to have and wear a film badge when working. Requests for film badges should be made to the Radiation Safety Officer. The film badge request shall have the following information:

    Name of Applicant (Printed or Typed)
    Date of Birth
    MHC ID# (from All-Campus ID card)
    Licensed Investigator's Name

    Users who are not Mount Holyoke faculty, staff or students must obtain a Mount Holyoke Visitor identification card from Auxiliary Services.

    Ring badges may be required when handling radioactive material in situations where the hand exposures may be significant. Ring badges may also be requested from the Radiation Safety Officer when needed.

  2. Bioassays
    Bioassays will be required of all researchers using 3H and/or 125I according to the following:
    1. Occasional use of 10mCi or more of 3H labeled compounds or 100mCi or more of other un-contained forms of 3H labeled material will require a bioassay within 48 hours after completion of the work. Continuous use requires weekly bioassays.
    2. Occasional use of carrier-free 125I for iodinations requires thyroid counting at 48 hours after completion of the work. Continuous use requires weekly bioassays.
    3. Bioassays for uptakes of other radionuclides will be done as determined by the Radiation Safety Committee prior to research authorization.

      The tritium bioassay procedure will consist of:

      1. Twenty-four hour composite urine samples will be collected by the individual involved as requested by the Radiation Safety Committee or Radiation Safety Officer.
      2. Calibrate the Liquid Scintillation Counter.
      3. 1ml of tap water in 10ml fluor will be used for the background count.
      4. 1ml of urine in 10ml fluor is counted for 10 minutes in the Liquid Scintillation Counter. Record counts.
      5. Add 10µl of 2x104dpm/10µl calibration solution to a second vial containing 1ml of urine in 10ml fluor and count 10 minutes in the Liquid Scintillation Counter. This permits accurate computation of counting efficiency even in the presence of quenching.

      For 125I thyroid counting, researchers will be counted at Mount Holyoke College at the appropriate time following the experiment. Two minute thyroid counts will be performed using an external scintillation probe with a single channel analyzer or multichannel analyzer system.

  3. Radiation Physicals
    Emergency medical examinations for anyone suspected of being overexposed to radiation may be arranged by contacting the Radiation Safety Committee or Radiation Safety Officer. Emergency medical examinations will be designed to satisfy the requirements of the particular emergency.

C. Personnel Exposure Investigation Levels

The College has established the following investigational levels as recommended by the NRC:

  Level  I Level  II
Deep Dose Equivalent 125 mrem/qtr 375 mrem/qtr. or
125 mrem/mo.
Eye Dose Equivalent 375 mrem/qtr. or
125 mrem/mo.
1125 mrem/qtr. or
375 mrem/mo.
Shallow Dose Equivalent to Skin or Extremities 1250 mrem/qtr. or
417 mrem/mo.
3750 mrem/qtr. or
1250 mrem/mo.

The Radiation Safety Officer will review all dosimetry reports from commercial vendors on a monthly basis. The following actions will be taken in those cases where exposure levels at least meet or exceed the investigational levels listed above:

  1. Except when deemed appropriate by the Radiation Safety Officer, no further action will be taken in those cases where an individual’s exposure is less than Level I.
  2. The Radiation Safety Officer will review the exposure of each individual whose monthly exposures equal or exceed Level I. The Radiation Safety Officer will consider each such exposure in comparison with those of others performing similar tasks as an index of ALARA program quality. The Radiation Safety Officer will report the results of his reviews to the Radiation Safety Committee by e-mail or other correspondence. If the exposure does not equal or exceed Investigational Level II, no action specifically related to the exposure is required unless deemed appropriate by the Radiation Safety Committee. The review will be discussed at the next Committee meeting and recorded in the Committee Minutes.
  3.  The Radiation Safety Officer will investigate in a timely manner the cause(s) of all personnel exposures equaling or exceeding Investigational Level II and, if warranted, take action. A report of the investigation, actions taken, if any, and a copy of the individual’s incident report form will be presented to the Director of Environmental Health & Safety upon completion of the investigation. The details of these reports will be recorded in the meeting with the Director of Environmental Health & Safety and other appropriate College officials. The Director of Environmental Health & Safety and the Radiation Safety Officer will, at that time, decide on the appropriate corrective action.
  4.  In a case where a worker’s or a group of workers’ exposures need to exceed Investigational Level I, a new higher Investigation Level II may be established on the basis that is consistent with good ALARA practices for that individual or group. Justification for a new investigational Level II will be documented.

The Radiation Safety Committee will review the justification for, and will approve all revisions of Investigational Level II. In such cases, when the exposure equals or exceeds the newly established Investigational Level II, those actions listed in paragraph C above will be followed. The details of the investigation will be made available to NRC and State inspectors for review at the time of the next inspection.

VII. Procurement and Use of Radionuclides

A. Procedures for Procurement

Orders for radioactive materials must be documented on a Radiation Purchase and Receipt Report (Appendix H). Only authorized Investigators, or designated staff, can order radionuclides. The Environmental Health & Safety Office provides the Stockroom Manager with a list of faculty and staff members authorized to order radioisotopes. Investigators wishing to designate staff as authorized to order and receive radionuclides, must include ordering and receipt procedures in training for those staff and notify the Environmental Health & Safety Office that the person is authorized by the investigator to order and receive radionuclides.

Ordering information must be sent to the Radiation Safety Officer and Science Stockroom Manager the same day the material is ordered. When placing the order, the Investigator should specifically request delivery on a specific day on which the investigator will be available to accept the package, during normal working hours, Monday - Friday. No orders can be accepted on Saturday, Sunday or College holidays.

The Radiation Safety Officer reviews all order information to insure that the requested materials and quantities are authorized by the license and that possession limits are not exceeded. The Radiation Safety Officer maintains current radioactive material possession information.

B. Receipt of Radionuclides

All orders are received at the Science Center Stockroom. Upon receipt of the order, the Stockroom will contact the Investigator who will pick-up the package, or designate an authorized user to pick-up the package, at the Stockroom and return to their radiation lab to monitor the package. If the Investigator is not available to pick-up the package, the Stockroom will call an Investigator identified as a back-up to collect the package from the stockroom. If the package cannot be immediately picked up, it will be held in a secure stockroom location.

The Investigator or an authorized user will monitor the package before opening and monitor the packing material for contamination after opening in their lab using the procedure in Appendix D. The Radiation Purchase and Receipt Report (Appendix H) is then completed and the form sent to the Radiation Safety Officer.

C. Transfer of Radionuclides to Other Individuals

The transfer of radionuclides between individuals and/or laboratories is to be discouraged as a practice; however, where a real need exists it may be done.

No radioactive material may be transferred or used outside Mount Holyoke College, except with permission from the Radiation Safety Committee.

D. Transportation of Radioactive Material

  1. To comply with Federal, State, and Local regulations, radioactive material to be transported outside of Mount Holyoke College property boundaries must be packaged in accordance with U.S. Department of Transportation regulations. The Radiation Safety Officer can assist in preparing packages for shipment to ensure compliance with the regulations.
  2. Transportation of radioactive material within the College's property boundaries must conform to the following:
    1. During transit, the material shall be in the possession and responsible charge of an authorized user of the material.
    2. The transportation route and time should be planned so that there will be minimal foot-traffic encountered and also minimal radiation exposure to locations where low-level radiation measurements are being conducted.
    3. The material shall be transported in a closed, shatterproof container that is properly labeled.
    4. The measured dose rates shall not exceed:
      1. 200 mrem/hour (2 mSv/hour) at any point on the external surface of the container.
      2. 10 mrem/hour (0.1 mSv/hour) at one meter from any external surface of the package.
    5. The transferable surface contamination as measured by a wipe test shall not exceed 1000 dpm/100cm² of alpha or beta-gamma activity.

E. General Requirements and Precautions

  1. The minimum standards for handling radionuclides must meet Commonwealth of Massachusetts' Department of Public Health regulations 105 CMR 120. In addition, the recommendations of the National Council on Radiation Safety and Measurements (NCRP) are considered to be the basis of good practice and are valuable guides, especially NCRP Report 8, "Control and Removal of Radioactive contamination in Laboratories" and NCRP Report 30, "Safe Handling of Radioactive Materials".
  2. In addition to the Licensed Investigators' and users' responsibilities, a set of standard practices and procedures for laboratory work with radionuclides is given in Appendix C.

F. Leak Test Requirements for Sealed Sources

  1. Sealed sources and detector cells shall be tested for leakage and/or contamination at intervals not to exceed 6 months or at such other intervals as specified by the certificate of registration referred to in 105 CMR 120, not to exceed 3 years.
  2. Sealed sources designed to emit alpha particles shall be tested for leakage and/or contamination at intervals not to exceed 3 months.
  3. In the absence of a certificate from a transferor indicating that a test has been made within six months prior to the transfer, a sealed source or detector cell received from another person shall not be put into use until tested.
  4. Each sealed source fabricated by the College shall be inspected and tested for construction defects, leakage, and contamination prior to any use or transfer as a sealed source.
  5. Sealed sources and detector cells need not be leak tested if:
    1. They contain only hydrogen-3.
    2. They contain only a gas.
    3. The half-life of the nuclide is 30 days or less.
    4. They contain not more than 100 microcuries of beta and/or gamma emitting material or no more than 10 microcuries of alpha emitting material.
    5. They are not designed to emit alpha particles, are in storage, and are not being used. However, when they are removed from storage for use or transfer to another person, and have not been tested within the required leak test interval, they shall be tested before use or transfer. No sealed source or detector cell shall be stored for a period of more than 10 years without being tested for leakage and/or contamination.
  6. The test shall be capable of detecting the presence of 0.005 microcuries of radioactive material on the test sample. If the test reveals the presence of 0.005 microcuries or more of removable contamination, the Radiation Safety Officer shall be notified and the source shall be removed from service.
  7. Records of leak tests results shall be kept in appropriate units.
  8. It is the responsibility of the Licensed Investigator to ensure that such leak tests are performed.

G. Radioactive Material Contained in Equipment

All equipment which contains radioactive materials is regulated as follows:

  1. Equipment that is regulated by general license issued under 105 CMR 120.121 and 105 CMR 120.122 should be registered with the Radiation Safety Officer. (Gas Chromatographs, Liquid Scintillation Counters, etc.)
  2. Equipment that requires specific licensing, as with other radionuclides, must be approved by the Radiation Safety Committee.
  3. This equipment should be labeled with a "Caution Radioactive Material" sign or other label.

H. Control of Exposure to Radiation

The following guidelines govern the use of ionizing radiation in educational institutions and shall be distributed to students participating in demonstrations and/or experiments involving radiation at Mount Holyoke College:

  1. Individuals in the general population of any age should not receive an exposure exceeding 0.1 rem (1 mSv) total effective dose equivalent (TEDE) per year in addition to natural background and medical exposures. This limit applies to those persons who are not occupationally exposed. If an instructor or student of age 18 or greater is subjected routinely to work involving radiation, then he/she is an occupational worker and must be authorized to perform such work.
  2. Individuals using radioactive compounds in gas chromatography equipment must vent the cell-exhaust through tubing into an approved hood or trap. This procedure will avoid contamination of work areas from the release of radioactive tagged samples introduced into the system or from the accidental overheating of radioactive foils in the cells.
  3. Students should not receive whole body exposures exceeding 0.1 rem (1 mSv) total effective dose equivalent (TEDE) per year due to their educational activities. It is recommended that each experiment be planned so that no individual receives more than 0.01 rem (0.1 mSv) while conducting or participating in the experiment.

It should be emphasized that there is no difficulty in performing radiation experiments and demonstrations in conformity with the above recommendations if appropriate safeguards are provided.

VIII. Radioactive Waste Disposal

The Commonwealth of Massachusetts requires that all licensees maintain written records regarding disposal of radioactive waste material. In order for the College to meet the legal requirements, Licensed Investigators are required to maintain appropriate records on the waste drums. The Radiation Safety Officer will compile the appropriate records from the information supplied by the Licensed Investigators for State inspections. Each Licensed Investigator is responsible for the secure and safe storage of radioactive waste generated until it is picked up by the Radiation Safety Officer. This generally means temporary storage within the individual's laboratory. In addition, appropriate shielding and containment of vapors shall be considered by the Licensed Investigator.

If radioactive waste is removed from a laboratory by unauthorized individuals (namely, housekeeping personnel) contact the Radiation Safety Officer immediately.

The following information should be helpful in fulfilling this responsibility and outlines Mount Holyoke College's current procedures.

    1. Solid Dry Waste

      Solid disposable lab wear and materials are all segregated by radionuclide and either held for decay or placed in a 55 gallon drum for final disposal via shipment to an approved burial site by a licensed broker. Materials held for decay are those with half-lives less than or equal to 90 days. Materials with half-lives of greater than 90 days are shipped out after a suitable number of drums are collected.

      Special waste receptacles are provided by the Radiation Safety Officer to the various departments utilizing radioactive materials for the disposal of solid dry waste. These receptacles are identified with the magenta and yellow radiation symbol and the words, "Caution-Radioactive Material".

    2. Liquid Waste
      1. Non-hazardous liquid radioactive waste or used non-hazardous liquid scintillation fluids are disposed into the sanitary sewer via the laboratory sinks in radioactive material laboratories.
      2. Liquid Scintillation vials that contain less than or equal to 0.05µCi/gm of 3H or 14C are disposed of via a licensed broker if they are of a hazardous chemical base. If non-hazardous LSC formulas are used and the vials contain less that or equal to 0.05µCi/gm of 3H or 14C, these are disposed in the normal trash. LSC vials containing other radionuclides with half-lives of less than or equal to 90 days are segregated and held for decay, 10 half-lives, and then disposed as hazardous chemical waste or in the normal trash if non-hazardous formulas are used.
         
    3. Animal Carcasses and Associated Waste

      Animal carcasses containing radioactive material with half-lives of less than or equal to 90 days are stored frozen until 7-10 half-lives have passed and then disposed as non-radioactive waste.

Appendices

A: Radiological Occurrence Report

B: Student Exposure to Radiation

C: General Rad Reqmts/Precautions

D: Procedures-Opening Radioactive Pkg

E: MHC - Emergency Procedures

F: Safe Use of Radioactive Materials in MHC Research Labs

G: Protocol/Radionuclides Form

H: Radiation Purchase/Receipt Form

I: Radiation Safety Training Record

J: ICRP Radionuclide Groups