Radiation Safety Operations Manual - Portland State University

PORTLAND STATE UNIVERSITY

RADIATION SAFETY OPERATIONS MANUAL

RADIATION SAFETY OPERATING PROCEDURES (RSOP)

TABLE OF CONTENTS

RSOP Number

Title

101.1 ADMINISTRATIVE ACTIONS 601.1 RADIOACTIVE MATERIAL LICENSING 601.2 RADIOACTIVE MATERIAL LICENSE AMENDMENTS 901.1 LABORATORY INSPECTIONS 1001.1 LABORATORY RADIATION SURVEY 1001.2 LIQUID SCINTILLATION COUNTER (LSC) USE 1101.1 SAFE RADIOACTIVE MATERIAL HANDLING 1101.2 SEMI-ANNUAL RADIONUCLIDE INVENTORY 1501.1 RADIOACTIVE WASTE HANDLING & STORAGE 1501.2 RADIOACTIVE LIQUID WASTE DISPOSALS 1501.3 RADIOACTIVE WASTE PICK-UP BY RSO 1601.1 X-RAY MACHINE USE IN RESEARCH 1701.1 RADIOACTIVE MATERIAL SPILL 1701.2 LOSS OF RADIOACTIVE MATERIAL


RADIATION SAFETY

OPERATING PROCEDURE

101.1

ADMINISTRATIVE ACTIONS

I. PURPOSE This procedure describes the actions taken by the Radiation Safety Officer (RSO) and the Radiation Safety Committee (RSC) in response to specific issues relating to laboratories and/or licensees at Portland State University (PSU).

II. DISCUSSION The actions defined in this procedure are consistent with those recommended by state and federal rules for the safe use of radioactive material and are a direct extension of the Radiation Safety Program Guide.

Radioactive Material Licensure

Initial License Submission Finding Action

1a. RSO or RSC receives license application from prospective new Licensee or his/her designee.

RSO reviews application for accuracy, proper documentation of use, and anticipated applications. RSO submits application to RSC for approval and/or discussion.

1b. RSC approves license application RSO prepares license file for new Licensee and schedules pre-licensing inspection prior to license activation.

Amendments to Active License

2a. RSO or RSC receives license amendment from Licensee or his/her designee.

RSO reviews amendment for administrative accuracy, proper documentation of use and anticipated applications. RSO submits amendment to RSC for approval and/or discussion.

2b. RSC approves license amendment RSO amends license, communicates approval to

Licensee or his/her designee, performs decommissioning survey as required.

Request to Terminate Active License

3a. RSO or RSC receives formal request from Licensee to terminate license on an effective date.

RSO collects all remaining radioactive material by the termination date. RSO schedules a decommissioning survey of the laboratory following final move.

Reinstatement of Suspended Radionuclide License

4a. Corrective actions by the Licensee are submitted in writing to the RSO and accepted by the RSC.

License is reinstated.

Radionuclide Acquisition

Finding Action 5a. Identification of an unauthorized

radioactive material requisition, such as an unlicensed radionuclide, chemical form or radionuclide quantity (activity).

RSO contacts the laboratory and requests submission of an amendment form. Amendment is then approved by the RSC as an expedited request.

5b. Arrival of incorrect chemical form,

excessive activity or unauthorized radionuclide(s) at the receiving area.

RSO will not deliver the package(s). Laboratory will be contacted. If required, RSO will request submission of an amendment form. Amendment is then approved by the RSC.

As Low As Reasonably Achievable (ALARA) Violation

Finding Action 6a. ALARA violation Examples:

• Excessive contamination in laboratory • Radioactive material in regular trash • Excessive exposure reading on

dosimeter

RSO will record the events, and a minimum of three follow-up checks will be made within six months (9 months for dosimetry violations). A second similar finding shall result in suspension of the license until resolved by the Licensee and the RSC. During suspension, the laboratory may not use or obtain radioactive material from any source. Evidence of gross negligence or disregard for required safety practices will result in immediate license suspension.

Laboratory Inspection

Finding Action 7a. No items of non-compliance Copy of report is sent to Licensee. A copy is placed

in the Licensee file. Inspection is documented in RSO database.

7b. Items of non-compliance and

recommendations Copy of report is sent to Licensee. Inspection is

documented in RSO database. A reinspection will be performed at a later date. If no radioactive material is used within six months after initial inspection, upon next incidence of radioactive material use a full inspection will be performed.

No response required Following the inspection, the RSO will allow

sufficient radioactive material use to show improved compliance. If no radioactive material is used within nine months, no reinspection is performed.

Response required Licensee submits written response detailing methods

of preventing recurrence of deficiencies within 30 days.

No response in allotted time. RSO resends notification requesting response within

5 working days.

No response after 5 day extension

RSO requests response within 24 hours.

No response received Licensee is notified of suspension of license until

resolved by the Licensee and the RSC. During suspension, the laboratory may not use or obtain radioactive material from any source.

Inadequate response RSO notifies Licensee and requests amended

response.

Written response received RSO files written response in license file. Reinspection performed as described above.

Corrective actions implemented File completed reinspection form in license file.

Document performance of reinspection in RSO database.

Corrective actions not implemented after reinspection

Notification of recurring deficiency sent to Licensee, and RSC. Documentation performed in RSO database. Second reinspection performed at a later date. If no radioactive material is used, no second reinspection is performed.

Corrective actions not implemented after second reinspection

License is suspended. Notification of suspension sent to Licensee, Department Chair, and RSC. Documentation performed in RSO database. During suspension, the laboratory may not use or obtain radioactive material from any source. To reinstate license, a corrective action plan must be submitted in writing and approved by the RSC.

Training

Finding Action 8a. Personnel overdue for radiation safety

training. If less than 90 days, RSO will notify personnel of the

next training dates. 8b. Personnel overdue for radiation safety

training greater than 90 days RSO will notify worker and Licensee that worker is

suspended from using radioactive material. Once worker passes training, they shall be reactivated.

8c. Licensee overdue for radiation safety

training If less than 90 days, RSO will contact the Licensee to

register them for the next training. 8d. Licensee overdue for radiation safety

training greater than 90 days. Radioactive materials license is suspended until

Licensee passes training. 8e. Inappropriate training for type of work. (i.e.

completing Administrative training and using radioactive material)

Attend next radiation safety training session appropriate for work performed. If training is not completed, license or authorization is suspended until appropriate training is completed or other arrangements have been made with RSO.

Semiannual Radionuclide Inventory

Finding Action 9a. Exceeding drain disposal limits. RSO consults with laboratory staff to determine the

cause of the violation and correct as necessary. 9b. No record of radionuclide delivered. See action for 5a. 9c. Unable to physically locate radionuclide

indicated on inventory and no records exist to indicate either use or disposal.

See action for 5a.

9d. Missing record of radionuclide transferred

off campus or to/from another lab on campus.

See action for 5a.

9e. No inventory submitted by deadline. Licensee is contacted and requested to submit

inventory within 5 working days, unless other arrangements have been made with RSO.

9f. No inventory submitted after 5 day

extension. Licensee is contacted and requested to submit

inventory within 24 hours, unless other arrangements have been made with RSO.

9g. No inventory submitted after second

extension. Licensee is contacted and required to submit

inventory by the end of the day or license will be suspended unless extenuating circumstances prevail.


RADIATION SAFETY

OPERATING PROCEDURE

601.1

RADIOACTIVE MATERIAL LICENSING

I. PURPOSE This procedure provides the prospective licensee or new faculty member guidance on how to complete the required paperwork to obtain a radioactive material license at PSU.

II. DISCUSSION The State of Oregon Radiation Protection Services (ORPS) and the PSU Radiation Safety Program Guide require specific radioactive material licensure for each researcher using radioactive material sources, whether radionuclides or x-ray emitting machines. The Program Guide also requires that any classroom work with radioactive material for demonstration or instruction must be approved by the RSC prior to use. At PSU these authorizations are obtained by completing a radioactive material license application. The application is received, reviewed, and forwarded with recommendations by the RSO to the RSC. The RSC either approves the license application or requests additional information or editing of the license application. Upon approval, the RSO performs a preliminary inspection consisting of a review of the license application, its conditions, and the schematic of the rooms to be licensed. Once the preliminary license inspection and all of the conditions of the license application are satisfied, a radioactive material license is issued to the researcher or faculty member.

III. EQUIPMENT A. PSU email account B. Computer, PC or MAC C. Printer or software capable to making entries in online form D. Copy of laboratory’s radioactive material protocol(s)

IV. PROCEDURE

A. Log onto the PSU network and locate the online license application form on the Environmental Health & Safety (EHS) website.

B. Open the document C. Print the document if lacking compatible entry software, otherwise begin entering

information. D. The following steps describe the information required in the different sections and fields of

the form. These instructions emphasize online form completion.

1. Section one: Licensee information a. Fill in the Licensee’s name and degree (i.e. Ph.D., M.D., etc.). b. Record the Licensee’s title and department c. Enter the Licensee’s contact information d. Check the box for either research or instructional (classroom use)

i. Record the course number ii. Enter the duration of the course in months or terms (i.e. Jan – April or

Winter Term). 2. Section two: Radioactive material

a. Record the radionuclide, chemical form, physical form (i.e. solid, liquid, solid & liquid, or gas), and the total possession limit being requested.

b. Complete additional lines for each separate radionuclide (i.e. 14C, 32P, 3H). 3. Section three: Purpose and usage rate

a. For each of the radionuclides requested in section two, report the frequency per month and usage rate, in mCi.

b. Briefly describe the purpose of the usage or experiment type c. Record whether or not any of the experiments will result in a volatile

byproduct of airborne radioactive material. If yes is recorded, describe additional details on the protocol and protective measures planned.

4. Section four: Licensee training information a. Record the institution or agency where the Licensee acquired training on the

three important areas of radiation training. Include the approximate dates and training method (i.e. on the job or formal courses).

b. Record the Licensee’s experience with each of the radionuclides requested in section two.

i. Indicate the radionuclide, quantity used (in mCi), the institution or agency where the experience occurred, the approximate dates, and the types of use (i.e. research).

ii. Complete additional lines for each separate radionuclide (i.e. 14C, 32P, 3H).

NOTE: The Licensee must attend the PSU Refresher Radiation Safety Training, at a minimum, prior to licensure. Exceptions must be approved by the RSC.

5. Section five: Radionuclide handlers experience information a. Record the names and other information for each radionuclide handler.

Indicate whether or not any individual received radiation safety training in the past and report the institution or agency and approximate date when this training was given.

b. This must be completed for each individual to be included on the radioactive material license.

NOTE: If formal radiation safety training has not been received in the past by any individual, PSU Introductory Radiation Safety Training will be required. Those laboratory personnel who have had formation training in the past must attend the PSU Refresher Radiation Safety Training prior to authorization.

6. Section six: Radiation detection instruments a. Record the radiation detection instrument information (portable and fixed) b. Indicate the type of radiation the instrument detects the make, model, serial

number, and detector model number. c. Indicate each instrument’s expected use or purpose.

7. Section seven: Personnel monitoring (dosimetry) a. Check the appropriate box for radiation badge needs for all users in the

laboratory. If multiple radionuclides will be used, only consider those requiring dosimetry (32P).

b. Guidelines for dosimetry: i. All 32P users must have ring badges ii. Any open-beam x-ray machine requires whole body badges for all

personnel in the laboratory using the equipment. 8. Section eight: Facilities & equipment

a. List all rooms in which radioactive material will be used. Usage includes drain disposals, opening and storage of stock vials, and radioactive waste storage areas.

b. Include a sketch (scanned or drawn electronically) with completed application. Sketch must include locations of waste storage, hot sink locations, refrigerator and freezer locations, and other laboratory configuration details.

9. Section nine: Radioactive waste disposal a. Record the waste type and method of disposal for each radionuclide requested

in section two. i. Waste types include liquid, solid/dry, animal waste, chemical waste. ii. Methods of disposal include decay, RSO pick up, and drain.

b. Indicate the room(s) where each radionuclide waste will be stored and/or disposed.

10. Section ten: Radiation protection program summary a. This section is for completion as an acknowledgement of all the specific

radiation safety aspects of the laboratory. The licensee must review each of these and check the box for each.

b. If there are any questions or issues on any of these items, contact the RSO prior to submitting the application.

11. In lieu of a signature, the Licensee must record his/her name, PSU ID #, and the date of submission.

E. Submission and completion 1. Upon completion of the application, save it to the local workstation to preserve it by

either clicking on the “Print form” button and printing to .pdf using Adobe, or clicking on “File” on the menu bar and then “Save As” and saving a .pdf document to the local workstation.

2. If necessary the application may be printed by clicking on “Print form” and choosing a desired printer.

3. Submit the application to the RSO for review by either clicking “Submit by email” button or opening the email program separately and emailing the saved file on the local workstation to the RSO.

4. Upon receipt, the RSO will review the application for accuracy and consider the responses for safety. Once satisfied that the RSC will approve the application, the RSO will forward it to them with “Recommended for Approval” status.


RADIATION SAFETY

OPERATING PROCEDURE

601.2

RADIOACTIVE MATERIAL

LICENSE AMENDMENTS

I. PURPOSE This procedure provides guidance to Licensees and their laboratory staff on how to complete the required paperwork to modify a radioactive material license at PSU. Also included are those changes that require authorization.

II. DISCUSSION ORPS and the PSU Radiation Safety Program Guide require specific radioactive material licensure for each researcher using radioactive material sources, whether radionuclides or x-ray emitting machines. Included in this licensing process is the authorization for specific radionuclides, quantity of those radionuclides (activity), chemical forms, and specific locations where radioactive material is used. This means that any change to these four elements of the radioactive material license requires an amendment to the license, which must be approved by the RSC. The amendment process is detailed in the following procedure.

III. EQUIPMENT A. PSU email account B. Computer, PC or MAC with printer or software capable to making entries in online form C. Copy of laboratory’s radioactive material protocol(s)

IV. PROCEDURE

A. Log onto the PSU network and locate the online license amendment form on the EHS website.

B. Open the document C. Print the document if lacking compatible entry software, otherwise begin entering

information. D. The following steps describe the information required in the different sections and fields of

the form. These instructions emphasize online form completion. 1. Section one: Licensee information

a. Fill in the Licensee’s name, degree, license # (found on any recent receipt and use log sheet, past license amendment, or inventory paperwork), department, and office location.

b. Record the Licensee phone number, laboratory phone number, and email address.

2. Section A: Animal use If live animals will be used with radioactive material, contact the RSO prior to completing the rest of the amendment. There may be additional forms and processes to complete.

3. Section B: Radionuclide change(s) a. The four subsections allow for modifications of up to 3 radionuclides each.

i. Add new radionuclide(s): report the radionuclide requested, the limit requested, the usage rate per month (both in mCi), and briefly describe the purpose of the usage or experiment type.

ii. Add new chemical form(s): report the radionuclide for which the chemical form is to be added, the currently authorized chemical form(s), the requested chemical form(s), and a brief description of the purpose of the usage or experiment type.

iii. Increase radionuclide(s) limit: report the radionuclide(s) for which the license limit is to be increased, the current limit, requested limit, and usage rate per month (all in mCi), and a brief description of the purpose of the usage or experiment type.

iv. Delete radionuclide(s) or decrease radionuclide limit(s): report the radionuclide for which the limit is to be decreased or removed from the license, the current limit, desired limit (indicate “0” if deleting radionuclide), and briefly describe the reason for the modification.

ii. Use the next open field to describe any additional details about the changes requested in the previous sections.

iii. Record the Licensee’s experience with each of the radionuclides requested above.

i. Indicate the radionuclide, types of use or experiment, the amount of time the experience lasted, and the institution or agency where the experience occurred.

ii. Complete additional lines for each separate radionuclide (i.e. 14C, 32P, 3H).

iv. Report the expected disposal activities planned for the different radionuclides requested.

i. Waste types include liquid, solid/dry, liquid scintillation cocktail, animal waste, or chemical waste.

ii. Methods of disposal include decay, RSO pick up, and drain. iii. Provide building and room numbers for where each radionuclide waste

will be stored and/or disposed. v. Briefly describe any shielding that will be provided, if necessary for the new

radionuclide or activity limit, to minimize personnel exposure. vi. Check the appropriate box for the type of dosimetry required for the new

radionuclide and/or activity limit. If multiple radionuclides will be used, only consider those requiring dosimetry (32P).

vii. Record the radiation detection instrument information, including the manufacturer or brand name of the instrument, the model number, serial number, radiation detected, detector model number (if known), and indicate each instrument’s expected use or purpose.

4. Section C: Laboratory change(s) a. Record the building code and room number to be added to the radioactive

material license, if applicable. b. List all rooms that will have radioactive material contained inside, whether

being used, stored, disposed, or processed in some way. c. For radioactive material location addition only, include a sketch (scanned or

drawn electronically) with completed amendment. Sketch must include locations of waste storage, hot sink locations, refrigerator and freezer locations, and other laboratory configuration details.

d. Record the building code and room number to be removed from the radioactive material license, if applicable.

e. Document the date the space will be vacant so the RSO can perform contamination survey(s).

f. If a layout change, provide the building code and room number of the change and a sketch (scanned or drawn electronically) with completed amendment. Sketch must include locations of waste storage, hot sink locations, refrigerator and freezer locations, and other laboratory configuration details.

5. Licensee authorization section Provide the Licensee name, date, and PSU ID number. This is intended to be a unique identifier that is known only to the Licensee so he/she is able to acknowledge and administratively verify the amendment and its contents.

D. Submission and completion 1. Upon completion of the amendment form, save it to the local workstation to preserve it. 2. If necessary the amendment form may be printed by clicking on “Print form” and

choosing a desired printer. 3. Submit the amendment to the RSO for review by email. 4. Upon receipt, the RSO will review the amendment for accuracy and consider the

responses for safety. Once satisfied that the RSC will approve the amendment, the RSO will forward it to them with “Recommended for Approval” status.


RADIATION SAFETY

OPERATING PROCEDURE

901.1

LABORATORY INSPECTIONS

I. PURPOSE This procedure gives the laboratory worker guidance in preparing for and conducting laboratory inspections with the RSO.

II. DISCUSSION ORPS requires periodic laboratory inspections. At PSU these inspections are conducted by the RSO. The inspection consists of three distinct phases: administrative records review, interview with laboratory personnel, and contamination survey. Understanding how the inspection is performed and what the RSO expects helps speed up the process and minimize the chance of inaccurate information exchange. Inspections will be scheduled in accordance with section 9 of the Radiation Safety Program Guide.

III. EQUIPMENT A. Laboratory records B. Survey meter C. Gloves and other required personal protective equipment (PPE)

IV. PRECAUTIONS Documentation of all laboratory activities must be performed in accordance with the Radiation Safety Program Guide. Refer to Section 18 for document maintenance guidelines.

V. PROCEDURE

A. Preparation 1. Prior to the inspection, the RSO, or his/her representative will contact the laboratory to

schedule the inspection. 2. The lab manager or radiation safety contact should inform the Licensee and all

laboratory staff of the pending inspection and ensure that all records are current. 3. Monthly surveys for the month of the inspection should be performed prior to the

inspection. B. Inspection

1. The RSO, or his/her representative will perform the inspection using an inspection checklist in three phases, though they may be in different order and/or overlap:

a. Records review The following records will be reviewed during this portion of the inspection:

i. Radioactive material license and amendments ii. Monthly radiation and/or contamination surveys (meter surveys and

wipe tests) iii. Waste records including drain disposal documentation, in-lab decay of

short-lived waste, RSO pick up of waste, etc. iv. Inventory records including receipt and use log sheets, transfer

documentation, and shipment paperwork (outgoing only). v. Documentation related to calibration of radiation detection

instruments/machines, if available. vi. Prior inspection records

b. Laboratory tour The laboratory tour is intended to familiarize the inspector with the laboratory, the practices and policies of the Licensee, and ensure required postings, labeling, and documentation are in place including:

i. State of Oregon required postings: Notice to Workers, Notice to Radiation Workers

ii. “Caution – Radioactive Material” signs and labels, where appropriate iii. Defined radiation use areas match those on the license or application iv. Personal space delineated and prominently posted. v. Evidence of food/beverage consumption and general safety review.

c. Radiation survey of laboratory i. Inspector performs a meter survey and a wipe test of the laboratory ii. Performs audit of trash receptacles for radioactive material

d. At any time during the inspection, laboratory personnel may attempt to correct deficiencies and have the inspector re-review the item(s) to eliminate a possible violation.

2. At the conclusion of the inspection, an informal close-out interview will be conducted explaining the findings, both positive and those requiring improvement. At this time, the inspector will make clear which findings will result in an “Item of Non-Compliance” and which will simply be “Recommendations.”

C. Following the inspection 1. The inspector will count all wipes and evaluate the survey results using standard Health

Physics guidelines. If contamination or a radiation-related safety concern exists, the inspector will inform laboratory personnel immediately. The results of the survey will be reported to the Licensee in the inspection letter.

2. The inspection checklist will be used to create a formal inspection letter. This letter will be written to the Licensee and will be the official documentation of the inspection.

3. Both the inspection checklist and the inspection letter will be sent to the Licensee and the laboratory contact, if applicable.

4. Reinspections and corrective actions:

a. In the event of items of non-compliance, the inspector may, at his/her discretion request a reinspection occur in accordance with Radiation Safety Operating Procedure 101.1.

b. In the case of more severe or extreme items, a formal response will be requested of the Licensee, in accordance with Radiation Safety Operating Procedure 101.1.


RADIATION SAFETY

OPERATING PROCEDURE

1001.1

LABORATORY RADIATION SURVEY

I. PURPOSE This procedure gives the laboratory worker guidance in performing and documenting laboratory radiation surveys as required by the Radiation Safety Program Guide Section 10.

II. DISCUSSION Documented, periodic, laboratory radiation surveys are required for laboratories and individuals using radioactive material at PSU. The Radiation Safety Program Guide states that these “surveys must be performed monthly when radioactive material is used.” The surveys consist of directly monitoring the laboratory for radioactive contamination with a survey meter and performing wipe tests for evaluation of removable activity. The following are exceptions to the requirements for radiation surveys in laboratories: A. Laboratories that exclusively use 3H or less than 40 µCi (received in stock vial) of other

radionuclides, are only required to perform wipe tests. B. Laboratories that exclusively use 32P are only required to perform meter surveys. C. Documented surveys are not required when radioactive material is not used in the lab in that

calendar month. These periods of non-use and non-survey must be documented in the survey log.

III. EQUIPMENT

A. Map of laboratory to be surveyed (see below for a template of the survey form). B. Dry wipes (Whatman filter paper or equivalent) C. Survey meter D. Protective gloves (i.e. vinyl, latex, nitrile) E. Liquid Scintillation Counter (LSC) or equivalent beta counting apparatus F. “Caution – Radioactive Material” tape or label

IV. PRECAUTIONS A. When using a survey instrument:

1. Do not contaminate the detector 2. Do not expose the detector to liquids 3. Do not use the detector in close proximity to sharp objects which may puncture and/or

damage the probe.

B. Protective gloves must be worn while conducting the wipe survey. C. Always use pencil to write wipe location numbers on the wipes. Ink interferes with liquid

scintillation counter efficiency. D. Always use biodegradable liquid scintillation cocktail when performing wipe tests. This

prevents the generation of mixed material, which is very expensive to dispose.

V. PROCEDURE A. Preparation

1. Obtain or sketch a laboratory map or layout diagram (see below for a sample form). It must include:

a. The locations of benches, hoods, desks, refrigerators, etc. b. All sink locations, including the “Hot Sink” and radioactive material use areas.

2. Number the locations on the diagram which are to be wipe tested. Number wipes (in pencil) to match the layout diagram

3. Obtain a survey instrument and perform the following checks on it. If any of these checks fail, contact the RSO.

a. Turn the range scale knob to “Batt” and verify that the batteries are satisfactory.

b. Turn on the instrument’s speaker, if available. c. Verify that the meter has been calibrated within the last year. d. Turn the range scale knob to its most sensitive (lowest) setting, while aiming it

away from any sources of radiation and record the background reading on the survey form.

4. On the laboratory diagram record the following: a. Building and room number b. Make, model, and serial number of the instrument used in the survey c. Background count rate of the instrument used d. Calibration date of the instrument used e. Initials or signature of the person performing the survey f. Date of the survey.

B. Direct Contamination (Meter) Survey

1. Survey from one side of the lab to the other with the survey instrument. 2. Survey for surface contamination by moving the detector at a speed that allows detection

of the radionuclide(s) used in the laboratory (usually 1-2 inches per second). 3. Survey at a distance of 1/4 inch to 1/2 inch from the surface being monitored, being

careful not to contact the surface and risking contamination of the probe. 4. Monitor desks, hoods, refrigerator handles, phones, laboratory equipment, etc. 5. Determine if something is contaminated with the 3 X Background thumb rule. 6. As areas of contamination are identified, clean the areas or mark with radioactive

material tape and return to clean them later. 7. If no contamination is detected, make note of it on the diagram (i.e. “no contamination

found”, “all areas at background”, etc.).

C. Wipe survey

1. Wipe the locations marked on the laboratory diagram using the numbered wipes. The area wiped should be approximately 100 cm2 per location.

2. Load wipes in liquid scintillation vials with an appropriate amount of liquid scintillation cocktail.

3. Load an uncontaminated (background or control) wipe in a separate vial with the survey wipes when prepared for counting.

4. Count the survey wipes and the background wipe with the counter 5. Obtain the results of the wipe test (print out) and determine the disintegrations per

minute (DPM) of each wipe. Some counters do this automatically in the programming and others do not. To calculate DPM from the counts per minute (CPM) results perform the following: DPM = CPM / efficiency Where efficiency is 50% for 3H, 80% for 14C, 33P or 35S, and 90% for

32P on most programs. For assistance with liquid scintillation counting, contact the RSO.

6. Calculate and record the minimum detectable activity (MDA) in DPM for the counter

by performing the following calculation:

2.71+ 4.71 𝐵𝑎𝑐𝑘𝑔𝑟𝑜𝑢𝑛𝑑 𝐸𝑓𝑓𝑖𝑐𝑖𝑒𝑛𝑐𝑦

7. Analyze the wipe results by comparing the DPM of each wipe to the MDADPM. Any

wipe that exceeds 2 X MDA in DPM must be investigated as follows: a. Recount the wipe. Sometimes static and/or the presence of chemi-

luminescent compounds can affect counting ability and result in erroneously high readings.

b. If the results are suspect, re-wipe the area of concern. c. If the results are confirmed or are believed to be valid, clean the area with

soap and water and then re-wipe. d. Continue in this fashion until either the contamination is cleaned up or there

is no more removable contamination (i.e. wipe tests show < MDADPM ). If you believe that contamination persists, but is no longer removable, contact the RSO for assistance.

e. Fully document the actions taken and retain LSC printouts of all wipes counted.

8. Attach LSC printout(s) and MDA calculation(s) to the survey form. Survey records should be kept in a log book in the laboratory and retained for two years.

PORTLAND STATE UNIVERSITY RADIATION SURVEY

DATE: CONTAMINATION RESULTS (

/100cm2) PI NAME

1

2

BLDG 3

4

ROOM # 5 6

7

8 9 10

MDA (DPM) 11 H-3: 12 C-14/S-35: 13 P-32: 14

METER SURVEY INFORMATION

15 16

17 18

19

MAKE 20

21

MODEL # 22

23

SERIAL # 24

25

PROBE # / SERIAL #

26

27

CAL DATE 28 29

BACKGROUND 30 31 REASON FOR SURVEY:

SURVEY RESULTS:

PERSON PERFORMING SURVEY


RADIATION SAFETY

OPERATING PROCEDURE

1001.2

LIQUID SCINTILLATION COUNTER (LSC)

USE

I. PURPOSE This procedure gives the laboratory worker guidance in the use of LSC machines at Portland State University (PSU). These specific instructions and precautions are based on technical manuals provided by the manufacturer and should prevent erroneous results and mishaps.

II. DISCUSSION LSC evaluation of radioactive material samples is essential for radioactive research laboratories for three reasons:

1. Allows for quantitative and qualitative experiment evaluation, and 2. Provides means for determining contamination of low level beta emitters that may be

below the detection level of other surveying methods (portable survey meter), and 3. Provides an accurate and documented method for determining activity disposed down

the drain.

Though the Radiation Safety Program Guide states the requirements for performing wipe tests and liquids prior to drain disposal, each laboratories’ specific experiment protocols determine whether LSC evaluation is necessary.

This procedure is divided into three sections within both the Precautions and the Procedure sections to provide information specific to the three different LSC models available on campus at PSU.

III. EQUIPMENT A. LSC

1. HIDEX 300 SL – SRTC 425E 2. Beckman LS6500 – SB1 29 3. Beckman LS6000IC – SB1 509

B. LSC vials with samples in them for counting C. LSC racks for the appropriate counter

D. Secondary container(s) for transporting vials between laboratory and LSC room E. Computer with access to PSU email and/or internet (HIDEX 300SL only) F. Printer with paper connected to LSC (Beckman models only)

IV. PRECAUTIONS A. HIDEX 300SL – SRTC 425E

1. General a. Do not under any circumstances open the vial tray unless a green light appears

on the front. b. Contact the RSO if you need assistance – do not troubleshoot the LSC on

your own c. Always count a blank / control so background can be determined.

2. Vial preparations a. Label the cap of the vial with either your name/initials or you PI’s and the

isotope in the vial b. Ensure vials are clean of any liquid scintillation cocktail and dry c. Tighten the cap of the vial – the LSC will pick up the vial from the cap. d. Make sure the counting rack is free of any obstructions e. Ensure that the appropriate size vial is used for the appropriate counter. The

HIDEX 300SL does not take large (20 ml) vials. 3. Computer precautions

a. Do not close the computer while the LSC is counting. This will cause the counting to stop because the laptop turns itself off.

b. Lock the computer workstation if you are leaving the LSC to count and leave the room. This lets the next person know that someone else is logged on and using the machine.

c. Do not turn off the LSC d. If the communication between the computer and LSC is disrupted, restart the

computer first. If that doesn’t work, turn off the LSC, shutdown the computer, restart the LSC and computer at the same time.

e. Do not disconnect the computer from the LSC. f. Do not remove the computer from the LSC room

4. Etiquette a. Make sure you leave the area clean when you are done. Take all vials with

you. b. Remember to log out of the computer when you finish counting so the next

person can use the LSC. c. If you do a large number of counts for several hours, try to have it run

overnight so others can use the LSC during the day. B. BECKMAN LS6500 – SB1 29

1. General a. Do not under any circumstances open the vial tray unless a green light appears

on the front.

b. Contact the RSO if you need assistance – do not troubleshoot the LSC on your own

c. Always count a blank / control so background can be determined. 2. Vial preparations

a. Label the cap of the vial with either your name/initials or you PI’s and the isotope in the vial

b. Ensure vials are clean of any liquid scintillation cocktail and dry c. Tighten the cap of the vial to prevent spillage. d. Make sure the counting rack is free of any obstructions e. Ensure that the appropriate size vial is used for the counting rack. If using a

large counting rack, ensure plastic adapters are used.

C. BECKMAN LS6000IC – SB1 509 1. General

a. Do not under any circumstances open the vial tray unless a green light appears on the front.

b. Contact the RSO if you need assistance – do not troubleshoot the LSC on your own

c. Always count a blank / control so background can be determined. 2. Vial preparations

a. Label the cap of the vial with either your name/initials or you PI’s and the isotope in the vial

b. Ensure vials are clean of any liquid scintillation cocktail and dry c. Tighten the cap of the vial to prevent spillage. d. Make sure the counting rack is free of any obstructions e. Ensure that the appropriate size vial is used for the appropriate counter. If

using a large counting rack, ensure plastic adapters are used.

V. PROCEDURE This next section is organized by the different LSC models with their specific operating procedures. A. HIDEX 300 SL – SRTC 425E

1. Log onto the laptop computer using PSU network login and password 2. Open the control software “Mikrowin” by clicking on the icon on the desktop 3. When the program opens perform the following steps:

a. Click on “open” icon (upper left) b. When the open file dialog box appears, switch the “files of type” from “.dat”

to “.par” – this will allow the parameter files to appear instead of the data files.

c. Find a parameter file that closely resembles your intended counting, ie P-32. Then find the parameter protocol that matches your method, ie 7 ml vials.

NOTE: PSU’s HIDEX 300 SL only has 7 ml vial trays, so selecting any program with 20 ml vials will require modification to the vial set up within the parameter file.

d. Double click the selection or highlight & click open. e. The basic programming for performing the count is now loaded, but can be

customized as follows: i. Open the parameter options window by clicking on the small window

next to “file name” in the lower left hand corner. ii. Count time: change the count time to the desired time in seconds.

Keep in mind others’ need for the machine. Only run large amounts for long count times after working hours.

iii. Activity type: always standard unless counting something at or near background (environmental samples).

iv. ROI: this is where the number and type of radionuclide for analysis can be changed. Most of the time will be just one except for wipe tests.

v. Data: these are the different data sets that can be exported with the data file. CPM, DPM and TDCR (efficiency) are the defaults and are all that most users should need.

vi. Delay before meas.: use if you want the machine to count the samples at a specific time.

vii. Repeats: use to set the number of times each vial is counted. viii. Vial selection: the system automatically counts all that have a black dot

in them. The counting starts with A1 and goes across the row. Vials can be deselected if you do not want them counted or do not have vials in them, but this is not necessary. The system recognizes the open vial spot and ends the count when a blank spot is identified.

ix. Spectra: used in unknown determinations x. When does adjusting settings, click “ok” in the upper right to close the

window. The settings will be saved and the window will close and the original window will appear.

f. Name the data file that will be created in the “file name” window. g. Click on “export” at the top, middle. This opens the file export dialog.

i. Choose “matrix export driver” from the drop down and click “browse” next to the file name box under “Export Target Information”

ii. Choose the location to have data exported. It is recommended that this location be a networked folder so access can be obtained someplace besides the laptop in the LSC room. Alternatively, a local location can be chosen and then move the data to a flash drive or email the file to yourself.

iii. Click “ok” and “ok” on the file export dialog.

h. Click Start. If the parameter file has not been saved, the system will prompt you to save it. However, do not save it as the name it has. If you get this error, click cancel and then go back and save it:

i. Sadfasdfsa ii. Asdfasdfasd iii. Asdfasdfasd

i. Sdfsdfs j. Sdfasdfas k. default parameter files)

4. B. BECKMAN LS6500 – SB1 29

1. Place vials in appropriate vial rack (7 ml or 20 ml). 2. Ensure printer has paper and the power is on. 3. Place desired programming card in the front of the vial rack. It should match the

program within the “edit user program” menu on the LSC. 4. Select “Count in automatic mode” on the screen and follow the on-screen instructions. 5. When done counting, remove printed data sheet and vials from counter. 6. Dispose of vials properly.

C. BECKMAN LS6000IC – SB1 509

1. Place vials in appropriate vial rack (7 ml or 20 ml). 2. Ensure printer has paper and the power is on. 3. Place desired programming card in the front of the vial rack. It should match the

program within the “edit user program” menu on the LSC. 4. Select “Count in automatic mode” on the screen and follow the on-screen instructions. 5. When done counting, remove printed data sheet and vials from counter. 6. Dispose of vials properly.


RADIATION SAFETY

OPERATING PROCEDURE

1101.1

SAFE


HANDLING

I. PURPOSE This procedure gives the laboratory worker guidance in performing many routine tasks associated with radioactive material use in the laboratory. These are intended to be general guidelines and practices, not specific actions. Specific instructions are available from the laboratory manager or licensee.

II. DISCUSSION Providing instruction to laboratory personnel on the safe handling of radioactive material is an essential component of the Radiation Safety Program and the RSO. By providing a list of safe practices and expectations, excessive exposure to personnel, contamination of equipment and facilities, and misunderstanding of radiation concepts are all minimized. Laboratory users of all experience levels benefit from this information.

III. EQUIPMENT A. Protective gloves (i.e. vinyl, latex, nitrile) B. Survey meter C. LSC or equivalent beta counting apparatus D. “Caution – Radioactive Material” tape or label E. Custom label to denote personal space, if required. F. Radioactive waste container(s) (available from RSO). G. Secondary container(s) for transporting samples. H. Shipping supplies (i.e. boxes, packaging materials, tape, etc.). I. Computer with access to PSU email and/or internet

IV. PRECAUTIONS A. When working with radioactive material: B. Always wear PPE (gloves, eye protection, lab coats).

C. Consider others’ exposure D. Perform routine contamination surveys with meter and/or wipes. E. Portable radiation survey instruments are required to be calibrated annually and kept in good

working condition. F. Liquid scintillation counters must be serviced and/or calibrated annually. G. Stock vials of radioactive material must be secured from unauthorized access. H. Shipping and receiving of radioactive material should be handled by the RSO. I. A laboratory preliminary license inspection is required by the RSO or his/her designee prior

to commencing radioactive material work and following approval by the RSC. J. Radioactive material should not be stored in hallways or areas without a locking door. K. Prior to shipping any material off-campus, the RSO must obtain a copy of the radioactive

material license from the receiving institution/organization.

V. PROCEDURE A. Setting up laboratory for radioactive material work

1. Using the approved radioactive material license as a guide, mark off radioactive material use area(s) with “Caution – Radioactive Material” tape.

2. Place “Caution – Radioactive Material” warning on door(s) to all rooms where radioactive material will be used, based on the approved radioactive material license.

3. Cover bench(es) and other areas that could become contaminated with disposable or cleanable materials (i.e. bench top paper, glass, etc.).

4. Mark any sinks that will be used to dispose of radioactive material down the drain with “Caution – Radioactive Material” tape. Post drain disposal log sheet in the proximity of the sink.

5. Place radioactive waste container(s) where designated on the approved radioactive material license. Post waste log sheet in the proximity of the waste container.

6. Identify storage location, refrigerator or freezer, where radioactive material will be stored. Ensure these are locked upon initial placement of radioactive stock vial(s).

7. Identify area(s) where personnel are allowed to keep and consume food and/or beverages based on laboratory policy, provided that they are not immediately adjacent to radioactive material use areas. These areas may be posted as “Personal Space.”

8. Obtain PPE for all laboratory personnel expected to use radioactive material, based on approved radioactive material license.

B. Ordering and receiving radioactive material 1. Place order with desired vendor by any means necessary. 2. Communicate confirmation of the ordered material to the RSO to assure radioactive

licensee limits are not exceeded. 3. Upon receipt, ensure correct material was received, review packing slip and receipt and

use log sheet. 4. Place radioactive package in appropriate area, open it and perform wipe test on stock

vial.

5. After ensuring stock vial is free of contamination, place vial in secure storage location (i.e. refrigerator, freezer, cabinet).

C. Transporting radioactive material 1. On campus

a. Obtain secondary container large enough to contain the total volume of material in primary container.

b. Use a utility cart if necessary/possible to prevent the chance of dropping the material.

c. Handle only the secondary container when outside the lab. Do not wear gloves.

2. Off campus / shipping a. Determine item(s) to ship and contact the RSO. Inform him/her of the

radionuclide and activity to be shipped. b. The RSO will inform the lab person organizing the shipment of the packaging

requirements and instruct the lab person how and when the shipment will take place.

c. Obtain shipping paperwork from the shipping company (FEDEX, UPS, USPS).

d. Bring the material in an unsealed shipping container (box, padded envelope, etc.) to the RSO.

e. Once shipped, the RSO will communicate any tracking information to the lab person.

D. Classroom use 1. Complete the radioactive material license application for instructional use. 2. Record the course number and duration of the course on the application. 3. Submit the completed application to the RSO. 4. Upon authorization, use in the classroom may commence in accordance with the

approved license application. 5. During the course, the instructor must keep a record of all students in the class and the

amount of time each student spent in proximity of the source. The instructor’s time must also be documented.

6. Submit this record of documented exposure to the RSO upon completion of the course.

E. Using radioactive material in the laboratory 1. Obtain proper protocol and observe all safety precautions. Ensure radioactive work area

is clearly established and that surrounding laboratory workers are aware of the radioactive work.

2. Set up all equipment and apparatus first. 3. Obtain survey meter, perform required checks, and turn it on. 4. Determine radionuclide, quantity (activity or volume), and chemical form. 5. Remove radionuclide from the stock storage location. Bring to the radioactive material

work area. 6. Remove required quantity of radionuclide, recap stock vial, and perform initial steps of

the protocol.

7. Once the experiment is in a safe condition, replace the stock vial in the secure storage location.

8. Complete the remaining steps of the protocol. 9. Upon completion or long-term waiting period (i.e. incubation, water bath, etc.) perform

contamination survey of work area with either wipes, survey meter, or both.


RADIATION SAFETY

OPERATING PROCEDURE

1101.2

SEMI-ANNUAL RADIONUCLIDE

INVENTORY

I. PURPOSE This procedure gives the laboratory worker guidance in performing and documenting semi-annual radionuclide inventories as required by the Radiation Safety Program Guide Section 11.3.

II. DISCUSSION ORPS requires periodic inventories of all radioactive material. To accomplish this at PSU, the RSO sends out inventory documents as listed in the procedure below. The purpose of these inventories is to “catch up” the records to reflect amounts currently in possession the laboratories. It is the responsibility of the radiation licensee to ensure the accuracy of these documents. Those laboratories that have not received any radioactive material since the last inventory simply communicate this to the RSO.

III. EQUIPMENT A. PSU email account B. Computer, PC or MAC C. Printer or software capable of making notations and corrections on documents emailed to the

laboratory D. Inventory documents including:

1. Inventory Memo from the RSO 2. Semi-annual radionuclide inventory report from the RSO 3. Lab-to-Lab transfer documentation form from the RSO

E. Copier

IV. PRECAUTIONS A. It is very important to verify that all of the receipts on each licensee’s list are accounted for. B. The RSO must be notified immediately of a missing vial of radioactive material or a missing

receipt and use log sheet. C. The completed inventory records should be copied and stored in the laboratory for 2 years. D. The inventory report includes all pertinent information about the radioactive material license.

The order of reviewing, editing, and inventorying is not important, but for purposes of

description, they are provided here in the order as they appear in the report: the license information first and the inventory portion second.

V. PROCEDURE A. Obtain the inventory documents that were sent by the RSO and either print them or prepare

them for editing or recording comments using computer software. B. Review the top portion of the inventory report and make any corrections necessary. Record

the status of the radioactive material license as “Active” or “Inactive” or “Wish to Cancel.” C. Review the list of personnel and mark “delete” for personnel no longer in the lab or at PSU.

1. If anyone’s “employee #” is blank, please fill in with their PSU ID #. Use student # if not an employee.

2. If any new people have joined the lab and are not on the list, record their name and PSU ID #, but in order for them to be added to the list they will need training – contact the RSO to register.

3. Review the training history and training due information for accuracy and inform any that are overdue of their need to attend training.

4. If any of the information is in error, make corrections and the RSO will correct it.

D. Review the survey meter information for accuracy. 1. If the meter(s) require calibration, bring them to the RSO or inform the RSO so they can

be picked up. 2. If any meter is not on the list, record manufacturer, model number, serial number, and

last calibration date, if known. 3. Note any survey instruments which need to be shown as out-of-service or removed from

the license. 4. Correct any erroneous meter information.

E. Review the building and lab information for accuracy.

1. Make a note in the “room type” field to inform the RSO of what the room is (i.e. main lab, LSC room, storage, etc.).

2. If any rooms where radioactive material is used are not on the list, add them. 3. If any rooms that are on the list require removal, line them out.

NOTE: Removing and adding rooms requires a license amendment – contact the RSO.

F. Radionuclide receipts. 1. Locate the laboratory’s radionuclide storage area and remove all of the stock vials and

place them in an appropriate work area (i.e. radioactive lab bench, hood, etc.). 2. Each radionuclide that the lab is authorized to use will be listed alphabetically and will

include the activity limit at the bottom of the list of receipts for each radionuclide. 3. Verify, using the license information and prior inventories that these limits and the

radionuclides authorized are correct. 4. The following is to explain the columns of the inventory section of the report, moving

left to right:

a. Receipt Key i. This number should match the Receipt Key on your “Radionuclide

Receipt and Use Log Sheet.” ii. If the item was a transfer into the lab, the Receipt Key number may

have a decimal, extra digit, and/or letter at the end. (i.e. 2699.1T, 2699.A, etc.).

b. Date and Activity (mCi) i. This is the day the radioactive material actually arrived in the lab and

the amount of activity received on the day the radionuclide was delivered to the lab.

ii. All activity calculations are based on the receipt date and the receipt activity.

c. Compound This is the chemical compound that was recorded from the packing slip at the time of receipt. Please ensure that this is accurate & change if necessary.

d. Non-Decayed Activity This is the activity of the receipt on the first day of the inventory period (10/1/2011). No changes need to be made to this column.

e. Decayed Activity This is the activity of the receipt based on the previous inventory or receipt date (whichever is later) and should reflect disposals made during the last inventory period – since no inventory was done in quite some time, this number may not be accurate. Don’t worry – it will be for next inventory.

f. Amount Disposed – 2 columns (Waste Given to RSO, Waste Drain Disposed)

i. Record the total amount of activity (mCi) disposed of as Waste to the RSO and Drain Disposed during the inventory period.

ii. If no disposals were performed, record “0” on these lines.

NOTE: Remember that the inventory period that these forms are regarding is from the previous 6-months. Disposals after that time do not count for this inventory period and all receipts should be decayed to the date the inventory was sent out.

NOTE: If you received any radioactive material that is not on the inventory list, record

the receipt date, nuclide, from where it came, the receipt activity, and inventory activity on the inventory paperwork.

G. Lab-to-lab transfers of radionuclides. 1. Print the “Lab-to-Lab Transfers of Radionuclides” form for use during the NEXT

inventory period. 2. Replace the older form, received with the LAST inventory, which now must be

returned with the other inventory materials if any radioactive material was received from or transferred to another licensee during THIS inventory period. If the lab had no transfers in or out during the past six months, please write “no transfers” on the form and return.


RADIATION SAFETY

OPERATING PROCEDURE

1501.1

RADIOACTIVE WASTE HANDLING & STORAGE

I. PURPOSE

This procedure describes the manner in which radioactive waste shall be stored and/or disposed by research laboratories at PSU.

II. DISCUSSION PSU is committed to maintaining radiation exposure to researchers and the general public As Low As Reasonably Achievable (ALARA). To achieve this, radioactive waste must be handled in accordance with the following procedure. Proper storage and disposal methods and accurate record keeping for radioactive waste are essential to the radiation safety program. In order to reduce waste build up in the lab and to stay within individual license limits, radioactive waste should be picked up or otherwise disposed of periodically. Radioactive waste disposal is provided by the RSO. Requests for radioactive waste pick up may be made by telephone or email to the RSO.

III. EQUIPMENT A. Protective clothing

1. Disposable latex, vinyl, or nitrile exam gloves 2. Lab coat 3. Eye protection when necessary 4. Radiation labels/tape

B. Provided by RSO as needed to lab: 1. Plexiglass or cardboard box(es) 2. Plastic bag inserts for box(es) and/or absorbent material for some waste types

C. Dosimetry badge(s) as necessary or required.

IV. PRECAUTIONS A. Minimize the handling of radioactive material. Always wear protective clothing and gloves

when handling radioactive material. B. Ensure that radioactive waste containers are conspicuously marked with radiation labels, log

sheets, and are placed in an area where they will not be mistaken as regular trash. C. Prior to generating mixed radioactive waste with biological, infectious, or chemical waste,

contact the RSO for disposal information. D. Dispose of sharp objects, glass pipettes, and needles in a sharps container before placing in

the radioactive dry waste.

V. DRY RADIOACTIVE WASTE NOTE: Radioactive waste must not be disposed of in regular trash The outside of all containers with radioactive waste must be clearly labeled with

“Radioactive Material” tape or labels. A. Storage in the lab

1. Radioactive waste shall be kept in a suitable container (cardboard or Plexiglass box) with a plastic bag liner and labeled “Radioactive Material.”

2. Radioactive waste should be stored away from regular trash 3. Biological or infectious waste, contaminated with radioactive material, must be stored in

red biohazard bags marked with “Radioactive Material” tape. Biological or infectious radioactive waste must be deactivated before discarding to the radioactive waste container or decayed to background prior to disposal as biohazard waste.

B. Laboratory storage for decay of radioactive waste 1. Only radioactive waste with half-lives < 90 days may be stored for decay in the

laboratory. Radionuclides with half-lives > 90 days must be given to the RSO for disposal. Each radionuclide must have its own collection container. Waste that is being held for decay must be stored for a minimum of 10 half-lives and be at background prior to disposal in regular trash.

2. A survey instrument must be used to monitor the waste. It should be set on the most sensitive (lowest) scale.

3. For low-energy beta emitters, hold detector at the surface of the bag at several points, including the bottom. Then open the bag and survey the inside of the bag without actually touching the detector to the waste. For high-energy beta and gamma emitters, survey in the same manner, but there is no need to open the bag.

4. The results of this survey must be documented and retained as records of decayed waste disposal. This can be accomplished by noting the survey details on the appropriate receipt and use log sheet or on the record sheet that accompanies this procedure (see below).

5. All radiation labels must be removed or obliterated prior to disposal in the regular trash. It is recommended that this is done before storing waste for decay.

C. Record keeping 1. Disposal of radioactive waste must be recorded. Information that must be included is:

radionuclide, activity, date, and initials of person disposing of the waste. The waste log must be kept on or near the waste container.

2. For record keeping related to the decay of radioactive waste, see B.4 above.

VI. LIQUID SCINTILLATION WASTE NOTE: The average concentration of LSC waste for RSO pick up must be less than or

equal to 0.05 uCi/ml. All containers and storage areas with radioactive liquid waste must be clearly labeled with “Radioactive Material” tape or labels.

A. Non-hazardous, biodegradable liquid scintillation cocktail 1. Before drain disposing of liquid waste, determine the activity using Radiation Safety

Operating Procedure 1501.2. Water must be running before, during, and after drain disposal.

2. After liquid scintillation cocktail vials have been emptied, they must be triple-rinsed with water and may be disposed of in regular trash.

3. Containers filled with liquid scintillation cocktail must be stored in unbreakable secondary containers. The container must be large enough to hold the entire contents of the primary container. Filled vials may be stored in their original cardboard trays or in containers provided by the RSO.

B. Hazardous liquid scintillation cocktail 1. Toluene, xylene, or other hazardous or non-biodegradable liquid scintillation cocktail

must be disposed of through the RSO. 2. Containers filled with hazardous liquid scintillation cocktail must be stored in

unbreakable secondary containers and in appropriate chemical storage areas. C. Record keeping

1. The activity of all liquid scintillation waste that is disposed of via the RSO or drain disposed must be accurate. See Radiation Safety Operating Procedure 1501.2 for drain disposal activity determination and documentation requirements.

2. A log sheet on the liquid scintillation waste container must be kept, which includes radionuclides, activity, volume (ml), and initials of user.

VII. LIQUID WASTE

Aqueous radioactive waste may be disposed of down the drain or by pick up by RSO. See Radiation Safety Operating Procedure 1501.2 for details on drain disposals and Radiation Safety Operating Procedure 1501.3 for radioactive waste pick up instructions.


RADIATION SAFETY

OPERATING PROCEDURE

1501.2

RADIOACTIVE LIQUID WASTE DISPOSALS

I. PURPOSE

This procedure describes the manner in which liquid radioactive waste shall be stored and/or disposed by research laboratories at PSU.

II. DISCUSSION In order to ensure that University drain disposal limits are not exceeded, the RSO has placed limits on the amount of radioactivity that may be disposed of down the drain on a per license basis. Before drain disposing of radionuclides, laboratory personnel must make an accurate determination of activity and compare this quantity to the current list of drain disposals for the month. This procedure is applicable to all who are authorized to use a sink drain for disposing of radioactive material.

III. EQUIPMENT A. Pipetter & tips B. Liquid waste container C. Liquid scintillation vials (LSC vial) D. Liquid scintillation cocktail E. Liquid scintillation counter (LSC) F. Calculator G. Lab coat H. Protective gloves and eye wear I. Drain disposal form J. Receipt and use log sheet K. Dosimetry badge(s) as necessary or required.

IV. PRECAUTIONS A. ONLY WATER SOLUBLE LIQUIDS MAY BE DISPOSED OF DOWN THE

DRAIN. B. Wear protective clothing, gloves, and eye wear when handling radioactive material.

C. Only sinks designated as “hot” sinks on the laboratory’s radioactive material license may be used for drain disposals. The sink area must be labeled with “radioactive material” tape or labels.

D. All containers exposed to or actively used for radioactive material storage must be clearly labeled with “radioactive material” tape or labels.

E. Containers with radioactive material present must include a log sheet for recording additions to the container and so all may see the quantity present.

F. The LSC is very sensitive to radioactive material detection. If an error occurs when counting “hot” samples, improved counting can be achieved by diluting the aliquot amount or choosing a smaller initial aliquot volume for counting.

G. If it is determined that the amount of activity removed from the stock vial is the amount of activity to be drain disposed (i.e. negligible dry waste generated), no LSC count of the liquid is required.

V. PROCEDURE A. Estimation of radioactivity prior to drain disposal

1. Sampling and counting radioactive liquids a. Collect and record the volume of radioactive liquid in a suitable container. b. Aliquot one milliliter (ml), or other appropriate volume of liquid and pipette

into an LSC vial. c. Fill vial with cocktail suitable for liquid sample counting. d. Place vial into LSC e. Determine counts per minute (cpm) from the LSC results

2. Calculate total activity a. Convert cpm to disintegrations per minute (dpm) using the efficiency of the

LSC and the following equation:

dpm = cpm / efficiency

Note: Efficiency will vary depending on the LSC, radionuclide, and instrument settings. Contact LSC maintenance vendor for details.

b. Calculate total activity by multiplying dpm/ml by total volume then convert to µCi:

dpm / aliquot volume * total volume = total dpm µCi = total dpm / 2.22 X 106 dpm/µCi

c. Check sink disposal limits in the PSU Radiation Safety Program Guide or on

the laboratory drain disposal log sheet (posted at the “hot” sink). On the drain disposal log sheet record the date, activity disposed, radionuclide, and initials. Dispose of the liquid accordingly.

3. Example: 500 ml of radioactive liquid 32P was collected over several weeks of experiments. One ml has been pipetted into an LSC vial. The vial has been filled with cocktail and loaded into an LSC. The resulting counts are 75,000 cpm.

a. Convert cpm to dpm:

75,000 cpm / 95% (Efficiency of counter for 32P) / aliquot volume 75,000 / 0.95 = 78,947 dpm/ml 78,947 dpm/ml X 500 ml = 3.95 X 107 dpm total

b. Convert dpm to µCi:

3.95 X 107 dpm / 2.22 X 106 dpm/µCi = 17.79 µCi

Note: All documentation for drain disposals must be retained in the laboratory for a minimum of 2 years.

B. Drain Disposal by “Averaging Method” 1. Perform above procedure at least 3 times on same protocol. The same initial activity

must be used each time. 2. When similar values are obtained for these LSC readings, take the average of the

calculated activity. 3. Use this value for subsequent drain disposals for that protocol. 4. This value should be updated when a significant number of people have left the lab

and/or the protocol changes. 5. This average should also be updated approximately every 3 years.


RADIATION SAFETY

OPERATING PROCEDURE

1501.3

RADIOACTIVE WASTE PICK-UP BY RSO

I. PURPOSE

To describe the manner in which radioactive waste will be removed from Portland State University (PSU) research laboratories requesting radioactive waste pick up. This procedure applies to radionuclides intended for onsite decay and for long-term burial off-site.

II. DISCUSSION The RSO is the responsible party for tracking and disposing of radioactive waste on campus. In order to reduce waste build up in the laboratories and to stay within individual and campus license limits, radioactive waste should be picked up periodically from labs. Requests for radioactive waste pick up may be made by contacting the RSO.

III. EQUIPMENT A. Radioactive waste log sheet(s) B. Receipt and use log sheet C. Phone and/or computer to contact RSO D. Survey meter E. “Caution – Radioactive Material” tape or label F. Calculator G. Lab coat H. Protective gloves I. Dosimetry badge(s) as necessary or required. J. Provided by RSO as needed by lab

1. Plexiglass or cardboard box(es) 2. Plastic bag inserts for box(es) and/or absorbent material for some waste types

IV. PRECAUTIONS

A. Radionuclides must be stored with those having a similar half-life. Generally those with half-life > 90 days are stored in one container and those with < 90 day half-life are stored in another.

B. No LSC vials, lead pigs, or free-standing liquid is permitted in any dry waste container. C. Waste forms must be segregated in separate containers (i.e. LSC waste in dry waste

container, pipette tips in liquid waste container).

D. Radioactive waste given to RSO for disposal or decay must be decayed to the date of pick up to assure accurate inventories and proper decay processes.

E. LSC waste and animals with radioactive material contained in their tissue being transferred to the RSO as waste must have a radioactive concentration < 0.05 µCi/ml or < 0.05 µCi/g respectively.

V. PROCEDURE A. Initial contact.

Contact the RSO to schedule a waste pick up. Have the following information at hand when scheduling: 1. Licensee name (Principal Investigator, or primary contact for radiation safety). 2. Laboratory location 3. Contact number for person arranging waste pick up 4. Type of waste (dry, LSC, or liquid) 5. Type of container (beta box, cardboard box, drum, plastic bag, etc.). 6. Radionuclide(s) and total activity (decayed) of each to be picked up 7. Type and quantity of replacement container(s)

B. Container preparation 1. Check containers for leakage, removable contamination, and/or overfilling. If any of

these conditions are present, corrective action must be taken to prevent the spread of contamination prior to RSO pick up. If in doubt or if you require assistance, contact the RSO or include a description of the situation in the waste pick up request.

2. Total the activity of each radionuclide in the container(s) before pick up and attach total to container (decay activity in container to the date of pick up before totaling).

3. Ensure that the container is marked with “Caution – Radioactive material” tape or equivalent.

4. Verify that LSC waste and/or animal waste containing radioactive material does not exceed 0.05 µCi/ml or µCi/g.

C. Removal of Radioactive Waste from Laboratory When the RSO arrives to pick up the waste, a receipt will be given as documentation of the pick up. File this receipt with radioactive use and disposal documentation. Ensure that the information on the receipt is accurate for the pick up.


RADIATION SAFETY

OPERATING PROCEDURE

1601.1

X-RAY MACHINE USE IN RESEARCH

I. PURPOSE

To describe methods for safely using and maintaining x-ray machines that are used in the research laboratory at Portland State University (PSU). This procedure applies to all x-ray machines that are not used for human diagnosis or treatment.

II. DISCUSSION The focus of the following procedure is to ensure that laboratory workers’ radiation exposure is kept as low as reasonably achievable (ALARA). The RSO is the responsible party for tracking and periodically inspecting all x-ray machines on campus. In order to reduce waste build up in the laboratories and to stay within individual and campus license limits, radioactive waste should be picked up periodically from labs.

III. EQUIPMENT A. X-ray machine

IV. PRECAUTIONS A. Only authorized users are permitted to make adjustments to x-ray machines while primary

beam is energized. . B. A radiation survey by the RSO is required following any change in arrangement,

components, disassembly, reassembly, initial installation, and during any maintenance, alignment, or when personnel exposures appear abnormal.

C. Maintenance on x-ray machines must be performed by a graduate student or above or a qualified service technician.

D. X-ray machine custodians (PI, Licensee, and/or department) are responsible for maintaining a specific list of authorized users and instructing users on the operational details of the machine they will be using.

E. All interlocking devices must be in place while primary beam is energized unless specifically approved by the RSO.

V. PROCEDURE A. X-ray machine acquisition

1. When x-ray machine is delivered to the PSU campus, contact the RSO and provide the following information to register the machine with the State of Oregon:

a. Owner/PI/Licensee/Department responsible for administration and maintenance

b. Location of installation c. Contact person, phone number, and email address d. Previous owner e. Previous owner contact information (phone, email, address) f. Machine information:

i. Manufacturer ii. Model iii. Control panel serial number iv. Technical data: kVP, mA, number of tubes v. Previously registered in Oregon? vi. Device type (XRD or XRF?), device style (fixed, portable, cabinet, etc.).

g. Is the machine replacing an existing machine? 2. Prior to final installation, ensure all users have completed x-ray machine training. Send

copies of certificates to RSO. 3. Once the machine is installed and registered, schedule an initial operational survey with

the RSO. B. Relocating, moving, repair, or modification of an x-ray machine

1. Inform the RSO of the intention to perform any of these operations. Provide the new location and/or reasons for occurrence.

2. Make arrangements with appropriate service organization to move the machine safely and/or perform maintenance.

3. Once completed, have RSO perform operational survey and safety inspection C. Transferring or disposing a machine

1. Inform the RSO of the intention to remove an x-ray machine from PSU’s inventory 2. If a machine will be acquired to replace the one leaving PSU, provide the information

above about the new machine. 3. If the machine will be transferred to a different institution, the receiving institution will

need the above information for registering the machine with the applicable state regulator.

4. If the machine will be sent for surplus, the machine must be rendered non-operational by removing the power supply cord or removing the fuses.


RADIATION SAFETY

OPERATING PROCEDURE

1701.1


SPILL

I. PURPOSE

To describe methods for laboratory personnel to respond to a radioactive material spill. This procedure is intended for those that are willing to perform any of these actions without the RSO, who should always be contacted in the event of a spill to ensure response and clean-up are conducted safely.

II. DISCUSSION The primary focus of this procedure is to minimize the spread of contamination and possible exposure to radiation after a spill. These considerations are necessary as part of the university’s emphasis on maintaining personnel radiation dose ALARA. While the RSO is the one primarily responsible for responding to and cleaning up a radioactive material spill, laboratory personnel may perform these actions based on their level of safety and ability. Within this context, two main categories of spill have been established: Major and Minor.

• Major spill: there is an immediate health hazard or widespread contamination. This includes any spill that involves personal injury. This type of spill requires RSO advice and/or assistance.

• Minor spill: the contamination does not present an immediate health hazard or risk of widespread contamination. Laboratory personnel who work in the laboratory where the spill occurred may clean it up in accordance with approved procedures.

Regardless of spill category, it is the responsibility of the responder to determine whether the spill is within his/her capabilities and to request RSO assistance if needed. In life threatening situations the first priority is preservation of human life; however it is essential that personnel minimize radiation doses and contamination spread to the extent reasonable under the circumstances.

III. EQUIPMENT

A. Personal Protective Equipment (PPE): 1. Lab coat 2. Safety glasses 3. Disposable gloves

B. Absorbent material (paper towels, etc.) C. Radioactive decontaminant (radiac wash, count off or similar) D. “Caution – Radioactive Material” tape E. Survey Instrument F. Filter paper for wipe tests G. Radioactive waste container H. Liquid Scintillation Counter (LSC)

IV. PRECAUTIONS A. Contact the RSO for advice or assistance for any radioactive material spill or contamination

incident. B. Only those assisting with spill clean-up should remain in area of the spill. C. Always wear appropriate personal protective equipment (safety glasses, lab coat, and gloves)

when handling radioactive material. D. Limit radiation exposure by working quickly, using shielding when appropriate/available,

and minimizing direct contact with radioactive material.

V. PROCEDURE A. Notify coworkers and other laboratory members that a spill has occurred.

1. Notify laboratory manager and/or Licensee. 2. Clear the area of all unnecessary personnel. 3. Consider establishing a boundary using rope, tape, or other material to prevent others

from entering and spreading contamination. B. Stabilize the spread of the liquid by covering with absorbent material (paper towels, lab

diapers). If excessive liquid, activity, or covering a large area, do not attempt to clean up, contact RSO and Campus Public Safety (CPSO) for assistance. 1. If necessary to confine personnel movement and/or to minimize the spread of

contamination, close the door and have CPSO maintain the perimeter. 2. Secure all ventilation, if possible (close fume hoods and biosafety cabinets).

C. Survey exposed skin, clothing, and shoes (tops and bottoms). 1. If shoes are contaminated, place plastic bags over them to prevent contamination spread. 2. If skin is contaminated, wash thoroughly with warm water and soap.

Do not abrade the skin. D. Begin spill clean-up:

1. Using disposable gloves carefully push absorbent material from the perimeter toward the center of the spill area.

2. Be careful not to re-contaminate any area previously surveyed. 3. Change absorbent material frequently to minimize contamination spread and absorption

into porous materials.

4. Place all cleaning materials and potentially contaminated PPE into radioactive waste container or bag(s).

5. Decontamination guidelines: a. Personnel

i. Wash affected area with warm soapy water. ii. Do not attempt to scrub vigorously without RSO assistance. iii. Contaminated clothing should be removed and stored for decay and/or

evaluation by RSO. b. Equipment/floors/benches

i. Clean with warm soapy water. ii. Contain all cleaning materials in radioactive waste container.

E. Perform a meter survey using a low-range, thin window GM survey meter. 1. Attention should be on:

a. The area around the spill b. Personnel clothing, hands, shoes, etc.

2. Continue to clean until the survey instrument no longer detects removable contamination when the cleaning material is placed in front of the detector.

3. If cleaning up a 3H spill, patience and attention is required as 3H is not detectable with GM survey meters. For this type of spill and at the point where GM survey meter(s) are no longer detecting contamination, wipe testing must be performed, see below.

F. Perform a wipe test of the area. 1. Wipe several affected areas within the perimeter of the spill and areas outside the area,

but still within the vicinity. Use caution not to contaminate subsequent wipes by changing gloves frequently.

2. If the LSC shows counts greater than twice the minimum detectable activity in disintegrations per minute (MDAdpm), then removable contamination is still present.

3. Continue decontamination until wipe test results indicate < MDAdpm. 4. If no contamination is detected by wipe test, but contamination remains via GM survey

meter (i.e. there is no removable contamination remaining): a. Cover the area b. Outline with “Caution – Radioactive Material” tape c. Label with: radionuclide, maximum dpm present, and date. d. Report this result to the RSO as soon as possible.

G. Estimate the activity disposed of as waste by estimating the volume missing from the spilled container (stock vial, tube, etc.).

H. Report the incident to the RSO as soon as possible and file an accident report.


RADIATION SAFETY

OPERATING PROCEDURE

1701.2

LOSS OF


I. PURPOSE

This document provides guidelines for laboratory staff and licensees in the event of a loss of licensed radioactive material. The main emphasis in this procedure is providing accurate information to the RSO for his/her reporting the incident to required regulatory bodies.

II. DISCUSSION This procedure applies to all users of all forms of licensed radioactive material (sealed, solid, liquid, or other forms). X-ray users and those in possession of naturally occurring radioactive material (NORM) and non-regulated material are not subject to most reporting requirements, and thus are not applicable to this procedure. The focus of the regulatory bodies, and hence, the RSO is ensuring that the PSU community, members of the public, and the environment receive radioactive exposure within ALARA guidelines. The RSO is the responsible party for tracking all licensed radioactive material at PSU. Under certain circumstances, radioactive material could be removed from secure locations. This may happen either by error or by deliberate action. Radioactive material may also be misplaced by an individual. Notification of missing radioactive material to the RSO is usually made by laboratory personnel.

III. EQUIPMENT Not applicable

IV. PRECAUTIONS A. A loss of radioactive material must be reported to regulatory agencies. Provide as much

information as possible to the RSO to ensure accurate and timely reporting.

V. PROCEDURE A. Contact the RSO and provide the following information:

1. Description of the missing material 2. Radionuclide 3. Activity 4. Chemical form

5. Physical form 6. Type of packaging and labeling the container had 7. Circumstances under which the loss occurred. 8. Detailed account of the actions taken in searching for the material. 9. Whether or not the loss of material was shared with the licensee

B. Despite any prior searching and investigation, the RSO will request additional actions and may visit the laboratory to assist in the search.

C. Once it has been determined that an actual loss of radioactive material occurred, the licensee must provide a written description of the incident to the RSO within one week.

D. Document on radioactive material log sheet(s) the loss of material and file the written report along with the log sheet(s).

Radiation Safety Operations Manual October 10, 2012 47

Internal (100.1, 200.1, 300.1 - corresponding to section of program guide) • RSC Meeting • Dosimetry • Bioassay • Training • Shipping RAM • Ordering RAM • Monthly Survey • Leak Test Survey • Waste

Dry Liquid LSC Animal? Chemical? Uranyl containing waste

f. determine the important molecular, atomic, isotopic, and radioactivity factors about the material

a. Formulas and molecular weights for various compounds: thorium nitrate: Th(NO3)4 = 480.06 thorium: 232Th = 232.08 t1/2 = 1.40 x 1010 years uranyl nitrate: UO2(NO3)2 = 502.13 uranyl acetate: UO2(CH2H2O2)2 = 422.13 uranium: 238U = 238.03 t1/2 = 1.41 x 109 years lead citrate: Pb2(C6H5O7)2 = 1053.82

2. set up the equation for the specific activity of the particular radionuclide(s) � = decay constant 1 Ci = 3.7 x 1010 Bq

a. Specific Activity (Bq/g) = �N = (ln2/t1/2)*(6.023 x 1023 atoms/mole)/(A grams/mole) =(4.174 x 1023)/(t1/2 * A) for t1/2 in seconds or =(1.323 x 1016)/(t1/2*A) for t1/2 in years

Specific Activity (Ci/g) = Bq/g * (3.7 x 1010 Bq/Ci) =(1.128 x 1013)/(t1/2 * A) for t1/2 in seconds or =(3.575 x 105)/(t1/2*A) for t1/2 in years b. Specific Activities:

232Th = (1.323 x 1016)/1.40 x 1010 * 232.08) = 4.07 x 103 Bq/g or =(4.072 x 103 Bq/g) (3.7x 1010 Bq/Ci) = 1.10 x 10-7 Ci/g

3. determine the mass of the particular radionuclides 4. calculate the activity

• XRD Survey • Radiography

Radiographer Responsibilities


Upon notification that an industrial radiographer has been contracted for work on campus the following documentation must be submitted to the University Radiation Safety Officer prior to the start of work. 1. A copy of the radiography company's current radiation license 2. Name of the RSO for the company performing the testing. 3. Isotope and quantity of the isotope to be used. 4. Most recent leak test certification for the source to be used. 5. Radiation monitoring equipment information (Type, manufacturer and calibration dates,etc.) 6. Names of the personnel performing the radiography work and current industrial radiography certification identification cards. 7. If the sealed source(s) activity exceed those quantities outlined in table 3, then the contractor must provide current T&R certification letters. 8. Dates, times and precise locations where the work will be performed. 9. Manner in which control lines will be determined and enforced. 10. Security plan. 11. Emergency contact procedures / contact information. In addition the radiographer must demonstrate to the university RSO that the following conditions will be met;

• That the radiation dose received by individual members of the public resulting from the licensees possession and/or use of licensed materials does not exceed 1 mSv (100 mrem) in one calendar year while the source is in storage on our campus.

• That the radiation dose in unrestricted areas does not exceed 0.02 mSv (2 mrem) in any one hour while the source is in use.

• That a control line will be established, whereby access will be restricted in areas where the dose rate exceeds 0.02 mSv/hr (2 mR/hr).

• How these control lines will be enforced.



RADIATION SAFETY

OPERATING INSTRUCTION

200.1

RADIATION SAFETY PROGRAM

AUDIT GUDE

I. PURPOSE This document gives guidance to any concerned party on the standard practices while performing an audit of the PSU Radiation Safety Program

II. DISCUSSION One of the responsibilities of the RSO at PSU is to ensure that an in-depth audit of the radiation safety program is performed annually and the findings be reported to the RSC. The following guide serves as a checklist for the areas of the program to be reviewed during the audit. This list is based on NUREG1556 Vol 11, but program elements may be added or eliminated based on current program scope and auditor expertise.

III. EQUIPMENT A. Checklist and other paperwork required to document audit findings. B. Survey meter(s) and detection equipment, as required C. RSO database D. Dosimetry (ring badge and/or whole body badge)

IV. PRECAUTIONS

A. Wear protective gloves when performing wipe survey B. Wear dosimetry (if necessary) while in radioactive waste area(s)

V. PROCEDURE

A. Management Oversight 1. RSC

a. Meeting documentation b. Approved license conditions/changes c. Demonstrated oversight of Radiation Safety Program (RSP)

2. RSO a. Documented on license b. Amendments, correspondence & program changes

3. Audits, reviews, or inspections a. Laboratory inspections


b. Prior audits of RSP 4. ALARA program

Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

B. Facilities 1. Access Control

a. Security of stored material b. Control of material not in storage

2. Engineering controls 3. Posting & labeling

a. Notices to workers b. Labeling containers

Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

C. Equipment & Instrumentation 1. Calibration of survey instruments 2. Calibration and maintenance of liquid scintillation counters (LSC)

Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

D. Material use, control, & transfer 1. License and applicable license conditions 2. Security and control

a. Restricted and unrestricted areas b. Security of stored material c. Control of material not in storage

3. Receipt and transfer of licensed material a. Compliance with dose limits for individual members of the public b. Procedures for receiving and opening packages c. Transfers d. Shipping e. Records of receipt

4. Shipping a. Documentation b. Training


Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

E. Laboratory Inspections 1. Periodicity 2. Citations & follow up 3. Documentation

Findings:___________________________________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________

F. Surveys & contamination control 1. Area surveys

a. Dose rates b. Survey records

2. Leak tests and inventories Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

G. Training 1. Laboratory workers 2. X-ray machine operators 3. Ancillary workers

Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

H. Radiation protection 1. Radiation protection program

a. Exposure evaluation 2. Dosimetry

a. Dose limits i. Occupational dose limits for adults ii. Occupational dose limits for minors iii. Doses to embryo/fetus

3. Records a. Records of radiation protection programs b. Records of surveys c. Determination of prior occupational dose


d. Records of individual monitoring results Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I. Radioactive waste management 1. Disposal

a. Labeling containers b. Records of surveys c. Records of waste disposal

2. Effluents a. Drain disposals

i. Records ii. Effluent concentrations & limits justification

b. Control of effluents i. Use of process or other engineering controls

3. Waste management a. Waste management documentation b. Waste storage areas

i. Security of stored material ii. Posting & labeling requirements

c. Packaging control, and tracking i. Transfer for disposal and manifests

Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

J. Decommissioning 1. Financial assurance and recordkeeping for decommissioning 2. Expiration and termination of licenses and decommissioning of sites and separate buildings or

outdoor areas Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

K. Notifications & reports 1. Individuals 2. Incidents 3. Reports of exposures, radiation levels, and concentrations of radioactive material exceeding the

constraints or limits


Findings:__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

II. Summary of audit findings __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________ ____________________________________

Auditor Date



RADIATION SAFETY


900.1

LABORATORY RADIATION

SAFETY INSPECTION

VI. PURPOSE

This document gives guidance to any concerned party on the standard practices while performing a laboratory radiation safety inspection

VII. DISCUSSION Laboratory inspections are a critical function performed by the RSO. These inspections ensure that users of radioactive material are conforming to the Portland State University (PSU) Radiation Safety Program Guide, state and federal radiation regulations, and normal safety practices. This is intended to be a guide on what to examine, where to look, and how to interact with laboratory personnel when conducting laboratory inspections, not a step-by-step set of instructions.

VIII. EQUIPMENT ii. Survey meter(s) and detection equipment, as required:

1. G-M detector count rate meter 2. Gas proportional count rate meter 3. Ion chamber dose rate meter 4. Filter paper (Whatman or equivalent) and envelopes 5. Check source(s)

iii. Record keeping equipment, as required: 1. Pencil and pen 2. Survey map of diagram of the lab(s)

iv. Reference materials and documentation: 1. Inspection form 2. RSO database preliminary inspection report, or equivalent

v. Additional forms/labels for posting: 1. “Notice to Radiation Workers” 2. “Notice to Employees” 3. “Store no Edibles” 4. “Caution – Radioactive Material” 5. “Radioactive Material” tape


vi. Personal protective equipment 1. Gloves (ok to obtain from lab) 2. Dosimetry (ring badge and/or whole body badge) 3. Lab coat

IX. PRECAUTIONS

C. Wear protective gloves when performing wipe survey D. Wear dosimetry (if necessary) while in the laboratory E. Wear lab coat while doing inspection F. If biological and/or chemical hazards exist, request and follow precautions given by laboratory

personnel. The risks due to biological or chemical agents may commonly exceed the dangers due to the radionuclides being used.

X. PROCEDURE A. Preparation

1. Prior to leaving for laboratory, review previous inspection report for Items of Non-Compliance in the license file or in the RSO database

2. Using the RSO database, obtain a preliminary inspection report, as follows: a. Click on “Licensing Information,” then “PI and Permit Information” from the drop

down menu. b. Either scroll down the list to find the licensee to be inspected OR click on one of the

letters from the alphabet listed above it. c. Scroll to the desired licensee’s name. Click on the “Reports” icon in the upper left

hand side of the screen, a drop down menu will open. d. Click on “Preliminary Inspection – RAM” then the Date Range for the report menu

opens. e. Click on the button for “Pick Your Own” and choose a date range for the year prior

to the inspection date (i.e. if the inspection will be on October 18, 2012, choose a data range of October 1, 2011 – October 18, 2012).

f. Click OK at the bottom of the page. Click on the printer icon in the upper left hand side of the page, print the report.

3. Select meter(s) based on radionuclides used in the lab during the date range, above. Check the batteries, replace if the meter needle does not deflect into the “Battery OK” (or similar wording) area.

4. Assemble other required items from the Equipment list, above, as necessary. B. Initial laboratory contact

1. Greet the licensee or laboratory contact or whomever will be assisting with the inspection. 2. If necessary, explain the nature of the inspection and any pertinent laboratory requirements.

C. General Instructions 1. Verify all information on the preliminary inspection report. Use the report as a checklist for the

inspection and make entries on it as the information becomes available. 2. Using the report, verify that the personnel list is accurate and training is current. Add any

personnel not on the list that use radionuclides to the list. If possible, include training date or


register for the next radiation safety training. Mark “delete” for personnel no longer in the lab or at PSU.

3. Records and reports for personnel a. Verify that dosimeter(s) are issued for personnel requiring them. If personnel have

dosimetry that is not required, ensure they understand it is their option to continue using badges (i.e. whole body badge for 32P use or any badge for 14C).

b. Verify training is current for all personnel listed on the report. 4. Documentation of Methods

1. Verify that the license is present and accessible in the lab. Verify the radionuclides, limits, and allowed chemical form(s) match. Verify that personnel know where to locate the PSU Radiation Safety Program Guide.

2. Use the summary report inventory section to review the radionuclides received during the past year to determine usage.

a. Start with the most recent acquisitions. Be sure to review all radionuclides obtained in the past year. If the list is extensive for any particular radionuclide, judgment is required to ascertain how many receipt and use log sheet(s) require review.

b. Inquire about if there has been any use of radionuclides not on the list. This may be the case with long-lived radionuclides, such as 3H or 14C.

c. Verify the lab’s receipt and use log sheet(s) have appropriate entries and that they accurately reflect the usage.

d. Compare entries on the receipt and use log sheet(s) against the monthly drain disposal records. Ensure that monthly drain disposal limits have not been exceeded.

3. If transfers have been performed, is the form completed properly? 4. Verify that survey instruments have a current calibration. Perform a source check and

battery check. Be sure the instrument(s) successfully pass these checks. 5. Radioactive material disposal

a. If drain disposals were performed, is documentation adequate? b. Obtain the types of waste generated for the radionuclides used in the lab. Include the

disposal method and room location(s) where the material is stored/disposed. 6. Laboratory surveys

b. Surveys of the previous twelve months should be verified. Periods of non-use must also be documented.

c. Meter surveys, wipe test results, and MDA documentation should be verified. 7. Other factors related to the use of radioactive material

b. Record the responses to the questions posed as they relate to radioactive material combined with the other hazards (i.e. phenol chloroform with 32P).

c. Are there any security problems? d. Are all radioactive material use locations listed on the report?

8. Postings of signs and notices a. Verify the proper postings:

A. “Caution – Radioactive Material” sign on lab door(s)


B. Current copies of the “Notice to Employees” and “Notice to Radiation Workers” posted in prominent location in the laboratory. They should be in plain view. If unable to find them, they need to be moved.

C. If laboratory does not have these, provide them. D. Benches, equipment, refrigerators, and freezers must be marked and/or

labeled to indicate use with radioactive material. E. Refrigerators must also have a “Store no Edibles” sign.

F. Ensure radioactive waste container(s) and hot sink(s) have log sheets to record radioactive material storage and disposal.

9. General laboratory safety a. Check all labeled refrigerators and freezers to ensure no food or beverages and

radioactive material are being stored in the same location. b. All lab members should wear lab coats when using radioactive material c. ALARA practices must be followed to maintain radiation and contamination levels as

low as possible. D. Radiation and contamination survey preparation

1. If there is no diagram of any of the rooms to be surveyed, sketch the room and then edit it upon completion of the inspection.

a. The sketch should include the entry to the lab and the location of benches, hoods, desks, refrigerators, sinks, etc.

b. Indicate which sink is the “Hot” sink (the sink where radioactive liquid waste is disposed).

c. Record the pertinent information for the survey instrument used during the direct contamination survey (S/N, calibration date, etc.).

2. Number the locations on the diagram that are to be wipe tested and, using a pencil, number the wipes accordingly.

3. Turn on the survey meter brought for the inspection to the most sensitive (lowest) setting away from any radioactive material and record the background reading on the survey form (usually around 50 cpm).

4. If the instrument is equipped with a speaker, turn it on. E. Direct contamination (meter) survey

1. Using the survey instrument, survey from one end of the lab to the other. 2. Monitor for surface contamination by moving the detector at a speed that allows detection for

the radionuclide(s) used in the laboratory (usually 1-2 inches per second). 3. Survey at a distance of 1/4 inch to 1/2 inch from the surface being monitored.

NOTE: Be careful not to puncture the detector face on anything sharp. Try not to interfere with any lab work.

4. Monitor desks, hoods, refrigerator handles, phones, laboratory equipment, “cold” sink drains,

centrifuges, etc. Check regular trash container contents. 5. On the laboratory diagram, record areas of contamination that are greater than 3X the average

background count rate. Notify lab personnel of contamination found as the survey progresses. F. Wipe survey


1. Using the numbered wipes, wipe the locations that correspond to the laboratory diagram. The area to be surveyed per wipe should be approximately 100 cm2.

2. Do not wipe papered surfaces or the inside of hot sinks. As a rule, equipment such as centrifuges and vortex spinners should not be wipe tested unless contamination is found during the meter survey. The areas wiped should be adjacent to work areas and locations that should not be contaminated.

G. Exit interview 1. Meet with the laboratory representative or the Licensee to review the inspection. 2. It is preferred that items be covered in the following sequence:

a. Mention areas that are excellent or very good. b. Provide information helpful to the lab where minor deficiencies exist. c. Explain any Items of Non-Compliance with reference to the PSU Radiation Safety

Program Guide and/or State of Oregon Radiation Safety Regulations. d. Encourage questions and/or comments about discrepancies and provide additional

information as necessary. e. Stress the importance of maintaining proper administrative records.

H. After the inspection and database entry 1. Count the wipes on one of the common use liquid scintillation counters within 1 business day of

the inspection. 2. After the wipes have been counted, determine the MDA and record the results of the survey on

the survey form. a. If results are less than the minimum detectable activity (MDA), record “< MDA” on

the form. b. If results are greater than MDA, record the disintegrations per minute (DPM) for the

wipe along with the standard deviation. 3. Record the inspection data into the database:

a. At the main menu click on “Health Physics,” go to “Compliance,” “Inspections,” click on “Inspection Results.”

b. Choose the Licensee that was inspected from the drop down menu. Click on “Add” in the upper left hand corner, highlight “Add Inspection”, scroll over and down to “Add RAM Inspection”.

c. Complete inspection date, inspector and permit # (use drop down for permit # and double click on the licensee if not already present). If the lab has had no use since the last inspection, enter “No use since last inspection, no inspection required” in the “Notes to Next Inspector” and the “Inspection Notes” fields.

d. Save the record. You are finished with the information required for a “no use inspection”.

e. Click on Associated Labs tab if lab info isn’t already visible. Click on the double arrow to populate the “Labs for This Inspection” window.

i. If there were no items of non-compliance, enter NINC in the “Notes to next Inspector” box.

ii. If there were violations, click on “Enter Violations/Deficiencies”. In the Violation Code drop down menu, double click on the violation code for the inspection. In the Comments/Observations box, enter the violation you observed at the inspection. Choose a response to enter in the “Response” box from the drop down menu. If the response you require


isn’t available, add it by clicking “Add”, type in the response and then click “Save”. If the item was corrected at the time of the inspection, check the “Corrected at time of inspection” box if that is the case. Click “Save” on the bottom right side of the screen to save the information. A pop-up window will appear asking if you want to add another violation. If you have more violations, click on “Yes” and add the info as above. If there are no other violations, click “No” and you will be returned to the “Adding RAM Inspection Results” page.

iii. Click “Save” to save the information you have added. To exit the database, click on “Exit” in the “Inspection Results” page then “Exit” twice from the drop down menu from the main EHSA page.

4. Corrective Actions a. If a response is required, the licensee will usually have fourteen calendar days to

provide a written response to any finding as a result of the inspection. Refer to Radiation Safety Operating Procedure 101.1 for corrective action guidance.

I. REPORT WRITING 1. The inspection report should be written within two weeks following the inspection. 2. Include the items of non-compliance (if any) and cite the applicable section(s) in the PSU

Radiation Safety Program Guide and/or the Oregon Administrative Rules (OARs). If a response is required, the licensee is usually given fourteen days to respond. On the bottom of the report page.

J. REINSPECTIONS 1. When approximately 3 months have elapsed since the inspection, a reinspection of the items of

non-compliance found during the inspection needs to be performed. 2. Make arrangements with the laboratory contact and/or licensee for the reinspection. 3. Obtain a copy of the inspection letter and a reinspection form. Complete the reinspection form

and mark the appropriate block for the citation(s) issued.

Go to the lab at the arranged time and perform an inspection of those areas associated with the citation. Other areas can be examined, but the main objective is to ensure that corrective actions have been taken.

5. If the lab has corrected the problem(s), report this fact to the contact and/or licensee and make sure they understand that there are no other actions required to correct the previous discrepancies. Check the box on the reinspection form marked “Resolved” and sign and date the form. Place the completed form in the inspection section of the licensee file.

6. If the problem(s) are still present in the laboratory and/or other problems are present, inform the contact/licensee and inform them of the possible ramifications for not correcting the problem(s) (See RSOP 201). Make comments and/or notations on the form stating in what way the items were not resolved. Sign and date the form.

7. Reinspection data entry. At the main EHS Assistant menu click on “Health Physics,” go to “Compliance,” “Inspections,” “Inspection Results.” Double click on the Licensee that was inspected from the drop down menu. Click on “Edit” then “Edit Deficiency/Violation”.

8. Go to the “Date Corrected” drop down located in the middle of the page. Enter the date by either entering the info in the “Date Corrected” box or choosing the date corrected from the drop down calendar. Enter the person who corrected the item in the “Corrected By” box. You may either enter “Licensee” or the actual person that corrected the items, if known.

K. REINSPECTION NOT REQUIRED


1. If at least six months have passed since the initial inspection and an item requiring a

reinspection hasn’t been performed in the lab, no reinspection is required. 1. Document the event on the Radiation Safety Reinspection form (Reinspect2003.frm) and

place it in the inspection section of the licensee file. 3. At the database main menu click on Health Physics, go to Compliance, Inspections,

Inspection Results. Choose the Licensee that was inspected from the drop down menu. Click on “Edit” in the upper left hand corner, highlight “Edit Inspection”, In the “Notes to Next Inspector “section, type in “No reinspection performed, no use since the inspection performed on (indicate the date the inspection was performed).

L. INSPECTION NOT REQUIRED

1. If, after reviewing the database for receipts, the licensee to be inspected has not received any

radioactive material for the twelve months since the last inspection, no inspection may be required.

2. Email the licensee contact or the licensee to verify no radioactive material has been used since the last inspection. Be sure to ask for a reply to the email you send. If the licensee responds that there was radioactive material used in the lab, perform the inspection as usual.

3. If the response indicates that there has been no radioactive material used in the lab, print out the response and place in the licensee’s file folder with previous inspection information.

4. Document the information in the database. See H.4-6. • Calibration



RADIATION SAFETY


1100.3

SEMI-ANNUAL RADIONUCLIDE

INVENTORY

I. PURPOSE:

This procedure provides guidelines to the Radiation Safety Office (RSO) staff for generating reports pertaining to the semi-annual radioactive material inventories. It also contains details concerning the performance of inventories, reviewing them and processing inventories into the database and the filing of the data.

II. DISCUSSION:

The radionuclide inventories are used to serve the following purposes:

1. To ensure the total amount of radioactive material on campus does not exceed the state licensed limit.

2. To demonstrate that receipt and disposal of radioactive material at OHSU is being monitored and is within the limits stated in the OHSU Radioactive Material License.

3. To serve as a quality assurance check against laboratory administrative records.

4. To ensure that internal license limits are not exceeded and that licensee activity amounts are accurate.

The review of updated lists and comparison with RSO records is important to ensure accuracy and completeness of the RSO database and files. The RSO and other licensees’ sealed source inventories are required every six months and are done at the same time as the semiannual inventory.


III. EQUIPMENT:

A. Licensee checklist

B. Inventory documents for each licensee

1. Semi-Annual Radionuclide Inventory Report 2. Lab-to-Lab Transfer Forms 3. Semi-Annual Inventory memo from Radiation Safety SO to all licensees 4. Guidelines for radionuclide inventory document.

C. Date stamping device

D. Computer with access to EHS Assistant database

IV. PRECAUTIONS:

A. When generating the inventory reports, pay particular attention to the Licensees being chosen to prevent sending erroneous information to the wrong campus’ Licensee(s).

B. Always send inventories to both the Licensee and laboratory contact person to ensure receipt and timely response.


V. PROCEDURE:

A. Preparation

1. Several days before the inventory is due to be sent out, find the following documents and ensure they are accurate, have the correct process for the laboratory members, and include the correct dates for the inventory period concerned: • the inventory email text (written by the Radiation Safety Officer). • the inventory guidelines document • the inventory memo (written by the Radiation Safety Officer).

These documents should be saved in an inventory folder to ensure accessibility when sending with the inventory.

2. On the day that the inventory is to be sent out, perform the following: a. Log onto OHSU Network, then log into the EHS Assistant database. b. Select the “Inventory” drop down menu, click on “Inventory Reports” and select

“Semiannual Inventory Report.” c. A menu for choosing the decay date will come up. Select “Today’s Date

Shortcuts” then “Today.” Click Ok. d. Next, a menu for selecting the licensees to specify the search on comes up (the

default sorting order of these is by PI Code). Highlight active licensees one at a time and click on the single arrow pointing to the right to add licensees to the data query. Pay attention to the permit numbers (WC indicates West Campus licensee).

e. When all the required licensees are listed on the right, click “Ok” to run the report.

f. Next, an additional date menu will appear. Select “Today’s Date Shortcuts” then “Today.” Click Ok.

g. The entire report will appear. Each individual page can be viewed by clicking on the arrows at the top. 1. Generate a master .pdf report by clicking on the printer icon, select “Adobe PDF”

from the printer name drop down menu and then click “Ok.” 2. A window will then open to determine the location and name for

the file. Save the report as a .pdf file, select the location for saving the file, and name the file. Close the report. The master .pdf file should be open.

3. To generate individual laboratories’ inventories: i. With the master .pdf document open, click the printer icon, select “Adobe

PDF” from the printer name drop down menu and choose the page range for the Licensee’s inventory (sometimes this is easier to do by making note of the page numbers for each Licensee prior to performing this step). Click Ok.

ii. A “Save PDF File As” window will open. Select the location for saving the file and name the file. Click Save. The new document will open. It can be kept open or closed, but it need not be re-saved.

iii. Continue generating individual Licensee’s inventories until all of them have been split off from the master inventory document.

4. To send the inventories via email to the licensee(s): i. Open the OHSU email system and generate a new email. ii. Enter the Licensee’s name and the contact’s name on the “to” line and then

copy and paste the text of the email as written by the Radiation Safety Officer.


iii. Attach the following documents to the email: • the licensee’s inventory • the transfer document for the new inventory period • the inventory guidelines document • the inventory memo (written by the Radiation Safety Officer).

iv. Click send. Repeat this process for all active licensees. 5. Once all of the inventories have been sent out, create a spreadsheet similar to the

one found at: X:\OHSU Shared\Restricted\ADMIN\EHRS\Radiation Safety\Inventory\West Campus Inventory Documents 2012\InvReceived.WC.1.2012.xls. This can be used to track receipt, identify which labs reported transfers, and document special circumstances with some laboratories (such as time off or expected date of response).

6. For Molecular Microbiology & Immunology radioactive waste inventory use a MS Excel spreadsheet. Ensure that the dates on it reflect the current inventory period. Leave the current inventory activity column blank to be filled in by the department waste coordinator. Print this spreadsheet out and mail it as all the other inventory forms.

B. Processing

1. As completed inventory forms are returned to RSO (via mail, email, or fax), print each one, date stamp the inventory and the transfer form.

2. Check off the license’s name from the spreadsheet by marking the date of receipt of the inventory and a Y or N for the transfer form column. If there is no information on the lab-‐to-‐lab transfer form or if it is not returned, write “N/A” in that column in the licensee’s row.

3. File the forms separately in alphabetical order. Continue in this manner until the inventory due date has passed (typically the 16th of the month that the inventory was sent out.

4. If some inventories have not been received after the due date, refer to RSOP201 for actions. 5. When all inventory forms have been returned to RSO, data entry and processing may begin as

follows: NOTE: The data does not have to be reviewed in any particular order.

4. Lab-to-Lab Transfer Forms a. Separate the Lab-to-Lab Transfer forms into two categories: those transfer sheets with

transfers done during the inventory period and those without. b. To avoid confusion with large numbers of transfers, using only those transfer sheets with

transfers, begin entering the data into a spreadsheet program such as Excel. This spreadsheet should have the following format:

Date Rec Key Nuclide Amount

(mCi) Lab to Lab From Lab Sheet Notes


10/8/2009 12908 P-32 0.05 Landfear Ullman Ullman

10/8/2009 12908 P-32 0.05 Landfear Ullman Landfear

The use of this format will facilitate sorting and improve efficiency.

NOTE: Data entered into the spreadsheet program should be done exactly the way it appears on the transfer sheet. This includes all mistakes clearly visible.

c. Sort the data entered by the date of transfer. Each transfer should now be listed twice: once from the transferor and the other from the receiver.

d. Look at these pairs of transfers and verify all the information on them. If any pair of entries contains discrepancies, highlight both transfers on the spreadsheet and continue reviewing the others. If there are any missing transfers (not a pair, but a single transfer) contact the lab to verify their transfer documentation. Make sure that the information recorded on the transfer matches the other lab’s information.

e. Once reviewing the transfers is complete, contact each lab with transfer errors to correct the discrepancies. Once the answers have been found, changes can be made on the transfer sheets and then fixed on the spreadsheet.

f. Print the spreadsheet and then enter each transfer into the EHS database, as follows: 1. Log onto OHSU Network, then log into the EHS Assistant database.

2. Open the “Waste” drop down menu, select “Removal of isotope from PI’s License,” then select PI from the “Show Inventory of PI” dropdown by double clicking on their name.

a. Locate the Inventory # (Receipt Key) corresponding to the transferring lab and double click the Inventory # to open the record.

c. Click on “Add Disposal” to open the “Adding RAM Disposal Record” window.

d. Record the transfer date from the spreadsheet at the top. Then click the drop down for “Transfer.”

e. Click the drop down on the popup menu and select the receiving PI from the list. Click the next drop down labeled “Lab” and select the primary lab for the PI and double click.

f. The inventory # (Receipt Key) for the receiving lab’s material will be the original number followed by a letter, A, B, C, etc.

g. Select “Some” or “All” for the amount of the original vial that is being transferred and then record the activity transferred in the next field.


h. Click “Check Permit Limits” to confirm that the receiving lab is authorized to receive and then click “Transfer Ready” to complete the transfer reporting. This will close the transfer sub menu and record the transfer details on the comments line. Click “Save.” If no further transfers occurred for this receipt, click “Exit.”

i. Continue recording transfers for all pairs of transfer records on the spreadsheet and file the transfer sheets and a printed version of the transfer spreadsheet.

5. Semi-‐annual Inventory Forms

a. Page Header: Review PI name, department, Permit number, and office and lab phone numbers for any changes the lab may have made.

b. Use Permit Information: Review radionuclides, chemical forms and possession limits for any changes the lab may have made.

NOTE: Changes to licensed radionuclides, chemical forms, and possession limits requires a license

amendment. If the laboratory indicates changes to these contact the lab contact/PI to verify that the information is accurate and advise them that they will need to submit a license amendment.

c. Laboratory Personnel: Review laboratory personnel information. It may be

necessary to remove or edit personnel records and/or change training records:

1. Editing laboratory personnel records:

a. Open the “Lab Workers” drop down menu, select “Lab Workers,” then click on “All” at the top of the screen. This makes all last names searchable. Type the first few letters of the person’s last name until he/she appears on the screen.

b. Double click on the person’s name to open their record. Modify the appropriate field on the top half of the record. On the bottom half, only “Training and “Attach/Detach PI” require editing.

1. Click on “Training” and then select either “Required Courses” or “Training History.” Edit as applicable.

2. Click on “Attach/Detach PI” then click on “Detach” to remove or “Attach” to add person to lab. Click “Save” to exit back to the “Lab Workers” list.

3. To archive a worker, highlight their name and click “Archive” at the top of the page. The database will confirm


this action, click “Yes.” The person no longer appears in the “Lab Workers” list.

d. Review of Previous Inspections: No review of this information is necessary as part of the inventory.

e. Survey Meters: Review the laboratory’s survey meters ensuring all are in calibration and that all information is present. Make any changes recorded by laboratory personnel.

f. Building and Lab Information: For any changes to locations/labs/rooms or hot sink(s), do the following steps to ensure consistent license management:

1. Review the license file for an amendment covering the change written on the inventory page. If the file does not contain the applicable amendment, contact the lab/PI, verify the information that they provided is accurate and advise them that a license amendment is required.

2. If the file does contain the applicable amendment, change the information in the EHRS database to update the license/location/radionuclide records.

3. Send license amendment forms as necessary to laboratories.

g. Inventory Verification: Review disposal amount entries for completeness. Calculate the total activity disposed of down the drain to ensure drain disposal limits were not violated during the inventory period. See OHSU Radiation Safety Regulations Sect. 18.2 for monthly drain disposal limits. If a licensee has exceeded a monthly limit, consult with the lab contact and/or PI to determine the cause of the discrepancy.

1. Recording inventory adjustments:

a. Open the “Waste” drop down menu, select “Removal of isotope from PI’s License,” then select PI from the “Show Inventory of PI” dropdown by double clicking on their name.

b. Locate the Inventory # (Receipt Key) on the list and double click on the Inventory # to open the record.

c. Click on “Add Disposal” to open the “Adding RAM Disposal Record” window.

d. Record the disposal date at the top and then the appropriate amount of activity with the corresponding disposal method. If the entire contents of the vial/shipment are disposed, click on the box next to “Totally Disposed” to mark the entry as having 0.00 uCi.


e. Click “Save” to exit back to the “Remove isotope from PI’s License” menu for the specific Inventory #. If no other disposals are required, click “Done” to return to the Inventory # list.

f. Continue recording disposals for all Receipt Key’s on the lab’s inventory.

2. When done recording all disposals for a lab, click “Exit”

NOTE: For Molecular Microbiology & Immunology, file the spreadsheet with other inventories.

Verify license limits are not exceeded. No adjustments should be made for these activity amounts.

6. File the different forms in separate labeled folders and place in filing cabinet for access at a later date.

B. Perform the RSO sealed source inventory and file it in the RSO Sealed Source Inventory Folder.

• Inventory • RAM Pickup • Data entry for all operation waste licensing - new, amendment, terminations decomissionings Decomissionings