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Official policies of St. Mary's University

Radiation Safety Plan (Environmental)


Executive Council

Authorizes release:

Vice President for Administration and Finance

Responsible office:

Administration and Finance

Review cycle:

Annually or as required



Last update:

September 2017

Next review:

June 2016


The objective of this plan is to provide the necessary procedures, guidance, and information for the safe use of radioactive materials at St. Mary’s University. While this plan does not include all radiation safety requirements, it does provide a detailed guide for users of radioactive materials. At present, the University holds no radioactive material licenses with the State of Texas. Only exempt amounts of radioactive material may be used on campus. A detailed list of exempt sources can be found at the United States Nuclear Regulatory Commission (USNRC) Regulation 10 CFR § 30.70 Schedule A – exempt concentrations and the Texas Department of State Health Services, 25 TAC § 289.251(l)(1). Those interested in reviewing more complete code requirements are encouraged to contact the University’s Radiation Safety Officer (RSO).

Radiation Safety Officer (RSO)

The Radiation Safety Officer (RSO) has the broad responsibility for monitoring, updating, and determining the degree of compliance with established regulations, policies, and practices regarding the license, purchase, shipment, use, monitoring, disposal, and transfer of radioactive material at St. Mary’s. The RSO will periodically provide a comprehensive briefing on the status of the Radiation Safety Program to the University Safety Committee.

Specific Duties of the RSO

  • Directs the radiation safety program.
  • Reviews “Intent to Submit” forms (“Blue Forms”) submitted to the Office of Academic Research that have identified the potential use of radioactive materials in the proposed research.
  • Submits applications and related correspondence for the licensing and registration requirements of the radiation safety program.
  • Reviews receipts of radioactive materials to assure that the procurement of such materials is not in violation of the radioactive materials license, that the material and user have been approved by the Radiation Safety Officer and University Safety Committee, and that suitable and secure storage and use areas exist.
  • Reviews all plans for the proposed use of radioisotopes and ionizing radiation producing equipment from the standpoint of radiation safety, outlines any additional requirements to the Principal Investigator, and makes recommendations to the University Safety Committee.
  • Assures that the monitoring, as required, and the opening of incoming shipments of radioactive materials is carried out properly, and supervises the storage and delivery of such shipments.
  • Supervises the packaging of radioactive materials to be shipped from the University to other authorized recipients to assure compliance with packaging, shipping and labeling requirements.
  • Ensures a physical inspection is made of each room or area where ionizing radiations producing equipment or radioactive materials are used to assure that the proper radiation warning signs are posted and/or containers are labeled.
  • Assures the issuance and wearing of personnel monitoring devices, when needed, their timely exchange, and the proper instructions on their use.
  • Supervises the wipe tests and surveys of storage and work areas in the laboratories where radioactive materials are located. Surveys all areas where radiation hazards are suspected and any other special surveys that may be required.
  • Determines exposure potential under actual or proposed working conditions and recommends time limits for personnel exposure and minimal working distances.
  • Investigates radiation incidents (spills or other mishaps), supervises the decontamination of major spills, and reports such incidents to the University Safety Committee and the Texas Department of State Health Services, as required.
  • Arranges for the collection of radioactive waste for proper storage and disposal and supervises the management of such waste.
  • Establishes proper calibration procedures for survey instruments that are currently in use or in a standby status and assures that qualified personnel perform these procedures in a timely manner. Also, arranges for prompt repair of survey instruments, as necessary.
  • Ensures that all required health physics activities are conducted; e.g., leak tests, wipe tests, survey records, dose records, receipt records, inventory records, etc., and that records of such are all properly maintained.
  • Develops and provides instruction for research and educational personnel in proper radiation safety practices and procedures and ensures that all users have read and understand the St. Mary’s University Radiation Safety Manual, which includes emergency procedures.
  • Possesses the authority to suspend any use of radiation that is judged to be a potentially serious radiation safety hazard or a flagrant violation of applicable rules.

Criteria for Users of Radioactive Materials

Basic Criteria

The following criteria are used as a guide in approving qualified personnel for specific uses of radioactive materials. A “user” referred to in these criteria means a qualified person performing experiments using radioactive materials. Guidelines are also included for “Maintenance and Janitorial Workers” performing their duties in radiation areas.

Each Principal Investigator (PI) and additional users of radioactive materials:

  • Must read, be familiar with, and follow the procedures outlined in this safety manual.
  • Submit a “Proposal to use Radioactive Materials” which must be approved by the Radiation Safety Officer (RSO) and the University Safety Committee before the experiments begin. The PI must sign all proposals. The RSO will assist in the completion of the proposal and will present the request to members of the University Safety Committee for evaluation and signature if approved. Approval will be granted if the Committee agrees that the proposed use satisfactorily meets adequate control and radiation safety requirements, and provides an appropriate plan for managing and disposing of radioactive material upon completion of the project.
  • Have the PI obtain an amendment to their proposal, approved by at least the RSO, before substantially deviating from the kinds of radioisotopes, the maximum activities, the areas of use, or the experiments described on the proposal. The RSO may approve minor changes in the proposal.
  • Shall indicate on the proposal additional users of the radioactive materials and describe their experience, training, and capabilities to safely conduct experiments using radioactive materials.
  • Must submit to the RSO curriculum vitae (CV) that is no more than five years old. The CV should include practical hands-on experience working with radioactive materials.
  • Will receive a proposal approval that is issued for a period not to exceed five years, at which time the proposal must be resubmitted to the RSO and the University Safety Committee for re-evaluation.

The RSO and University Safety Committee will approve proposals only if convincing evidence is provided that the user is competent in performing all applicable phases of the proposed experiments. If, after reviewing the proposal and supporting information, the RSO and/or Committee members have questions about the safety of the proposed use, they may require:

  • A personal interview with the PI for specific details of the experiment.
  • That the PI first makes a trial run of the experiment using non-radioactive materials.
  • Specific types of safety equipment and techniques to be used under certain conditions.

Classification of Users and Specific Criteria

Principal Investigator

To be designated as a Principal Investigator, an individual must have the approval of the RSO and the University Safety Committee. In granting this approval the following criteria, in addition to those cited elsewhere in this section, shall be used as a guide in evaluating the person. A Principal Investigator:

  • Shall be an experienced user of radioactive materials and considered competent in directing the proposed radiation program.
  • Shall be assured that the necessary funds are available to cover the costs of proper licensing and the costs of safely conducting the proposed radioactive experiments.
  • Is responsible for personnel within the program, ensuring that they have the ability to safely conduct their assigned duties.
  • Is responsible for submitting a proposal for each proposed use of radioactive materials. Each proposal must be signed by the PI and initialed by each user working under the proposal.
  • Is responsible for ordering, maintaining security, maintaining inventories and keeping disposal records of all radioactive materials authorized by the approved proposal.
The Specific Duties of Principal Investigators
  • Shall have a current and complete proposal on file with the RSO.
  • Shall observe all safety recommendations, rules and regulations of the University; the State of Texas and the federal government; and any special conditions required by the RSO and the University Safety Committee.
  • Shall immediately, report to the RSO any accident involving radioactive materials or equipment producing ionizing radiation.
  • Shall notify the RSO of shipments of radioactive materials that are received directly by the laboratory. The RSO shall be notified of all shipments or transfers of radioactive materials to and from the University.
  • Shall submit a quarterly inventory report for radioactive materials to the RSO. This report shall include the kind and amount of radioactive material on hand, receipts, and disposals, and shall indicate the method of disposal.
  • Shall ensure that all personnel who work with radioactive materials are listed on the proposal and have reviewed and are familiar with the applicable parts of this manual.

Radiation Worker

The position of Radiation Worker is established primarily for personnel who will be working with very low levels of radioactive materials involving minimal hazards. Direct supervision is required. Direct supervision means that the supervisor (PI) must work closely with the individual, physically demonstrate the procedures, and give instruction on the hazards of the experiment. The supervisor should be physically present, unless convinced that the worker understands the procedures and can safely perform the assigned duties. The supervisor should be readily available for the worker to contact in case of need. If the person has had no experience working with radioactive materials, that person, before conducting radioactive experiments, must work as a trainee for an initial period with the supervisor physically present. The trainee should make trial runs, when necessary, using non-radioactive materials until the worker can safely conduct or assist in conducting the radioactive experiments. Such a trainee should also take the Radiation Safety Short Course as soon as it is next offered. Since the short course is offered no more than once a semester, the trainee should be scheduled for one-on-one training with radiation safety personnel as soon as possible. This one-on-one training will usually consist of the trainee viewing radiation safety videotape and a question-and-answer session with the RSO present. Refresher training is required of every individual at intervals not to exceed seven years. 

Maintenance and Janitorial Personnel (special instructions)

Maintenance personnel who are required to work in laboratories where possible radiation hazards exist, must be informed of those hazards and be supervised when necessary. The PI shall notify the RSO before maintenance personnel start work on such projects so that proper safety will be provided. 
The following examples are types of projects that should be reported to the RSO before work is begun:

  • Changing filters in hoods in which radioactive materials have been used.
  • Working on drains of sinks that have been used for the disposal of radioactive materials.
  • Working on laboratory equipment that is likely to be contaminated with radioactive material.

Janitorial workers must be apprised of any radiation hazards present and the meaning of warning signs and labels. The RSO can provide this training whenever necessary.

Radioactive Material Accountability

Ordering, Receiving, and Transferring Radioactive Materials

All radioactive material shipments shall be coordinated by the RSO. All shipments, packaging, and transportation of radioactive materials from or by the University to outside agencies shall comply with the requirements of 25 TAC § 289.257, the Department of Transportation, and all other applicable state and federal regulations.

Requisitions for radioactive materials shall not be submitted if such materials and quantities, plus the materials and quantities on hand, exceed those listed on the PI’s proposal as approved by the RSO and the University Safety Committee. 
All incoming packages of radioactive materials shall first be delivered to the RSO’s office. The package will be checked for integrity, monitored in accordance the State of Texas Standards for Protection Against Radiation, and delivered to the appropriate laboratory.

Transfers of radioactive materials to other facilities must be coordinated with the RSO. Such shipments must be properly packaged, labeled and wipe tested, as necessary. The RSO must have a copy of the recipient’s license number as proof that the individual is authorized to receive the material.

When transporting radioactive material, particularly radioactive liquids in glass containers from one laboratory to another, a secondary container; such as, Styrofoam, cardboard, rubber, or metal must be used. When millicurie (mCi) amounts of radioactive solutions are transported, enough absorbent packing material shall be used to ensure that all the liquid is absorbed in case of breakage or leakage. Vehicles used for transporting these radioactive materials should be checked for contamination after use and decontaminated, if necessary.

Inventory of Radioactive Materials

Each Principal Investigator that uses radioactive material (licensed and exempt) is required to keep an inventory of radioactive materials in their possession. Inventory reports should be submitted annually to the RSO at the beginning of the fiscal year (June 1). Serious delinquencies may result in punitive action by the University Safety Committee. Upon request, the RSO can provide radioactive material inventory forms. The inventory forms are for reporting the amounts of each radionuclide received, transferred and disposed of during the reporting period, plus the amount of each radionuclide “on hand” at the end of the reporting period. Alternate methods of reporting equivalent information may also be used. 
The activity of a radioactive source at any time can be determined from

where A(t) is the activity at time t, A0 is the initial activity, t is the elapsed time since initial activity, and T1/2 is the half-life of the radionuclide. Note that T1/2 and t must be in the same units.

Laboratory Controls to Minimize Radiation Exposures

Controls within facilities where radioactive materials are used or stored are established to minimize radiation exposure and radioactive contamination. High standards of cleanliness and good housekeeping, proper supervision, and well-instructed personnel are significant elements in the control of radiation exposures and radioactive contamination. The PI is responsible for seeing that these conditions are met on a day-to-day basis in their laboratory.

Personnel Protective Measures

Eating and drinking are prohibited when working with radioactive material. Protective gloves are required when working with loose radioactive material (powder or liquid). Surveying (when appropriate) and washing hands is required after working with loose radioactive material. Handling radioactive material should not be done if there are significant breaks in the skin (cuts or abrasions) that would permit entry of radioactive material or hinder the effective decontamination by vigorous washing.

Laboratory Procedures and Facilities

Each person working in the laboratory shall clean up their work area and apparatus, and properly dispose of or store any radioactive material. No person or object subject to radioactive contamination is to leave a laboratory without being monitored for radioactivity. Suitable monitoring techniques are required; such as, using a G-M survey meter or conducting wipe tests. Consult with RSO if specific instructions are needed as to the proper technique for radiation monitoring.

Tables and bench tops on which radioactive material is used shall be made of, or lined with, a nonporous and chemical resistant material. Such surfaces are to be covered with a disposable material such as absorbent plastic-backed paper. When working under conditions that a spill or incident would not be confined to a small area, the work shall be done over a tray, or other provisions should be made to minimize the extent of a contamination incident. The extent of work areas and storage places for radioactive material within a laboratory are to be kept to a minimum.

Storage of Radioactive Material

Radioactive material is to be stored as far as practical from other work areas and behind sufficient shielding (lead for gamma emitters, plastic for beta emitters), when needed, to minimize the exposure of personnel. The exposure level should at no time be greater than 2.0 mR/hr at the surface of the storage container (closed). If the PI is uncertain on how best to properly store radioactive material, he/she should contact the RSO.

Signs and Labels

Radiation warning signs bearing the standard radiation symbol and proper wording must be posted in areas subject to radiation hazards when required by state and federal regulations. Containers of radioactive materials must bear labels with the radiation symbol and words “Caution (or Danger) Radioactive Materials”, and list the radioisotope, the amount of activity, the activity date, the PI’s name and contact information. Additional information on or near the containers may be provided if it will help minimize radiation hazards. Posting of signs must be in compliance with Texas Regulations for Control of Radiation, 25TAC § 289.202(z)-(dd). For advice as to proper signs and posting in restricted areas, consult with RSO.

Disposal of Radioactive Material or Waste

Radioactive material or waste is not to be discarded by regular means of disposal. Specific rules, regulations, and guidelines must be followed for the disposal of radioactive material or waste. Emphasis is placed on the segregation of different types of waste according to radionuclide, half-life, chemical form, physical form, or combinations thereof. All radioactive waste disposals must be reflected on the inventory. Please contact the RSO for the proper waste disposal procedures.

Inventory and Registration of Radiation Machines

Equipment with the potential to emit radiation (i.e. x-ray unit) shall be dispositioned as active or inactive.   The equipment shall be inventoried with status and documentation retained by the RSO. Requirements for radiation safety officers can be found in §289.226(t)(1) Registration of Radiation Machine Use and Services. Form: RC 42-3 RSO form.

  • If the unit is active, it shall have a current registration certificate on file with the RSO. Warning signs will be attached to the unit. The RSO will provide safety training for all personnel (and students) using the equipment.
  • If the unit is inactive, it should be dispositioned for disposal through Physical Plant. Disposal of equipment will include disabling the unit, removing any components with oil, and testing the oil for PCBs. Disposal method will depend on the presence of PCBs.

What is the process for transferring a piece of equipment?
The registrant will need to submit a completed RC-18R Radiation Machine Transfer & Disposal form indicating disposition of equipment. The form must be signed and dated by the RSO.

What is the process for terminating a site?
The registrant will need to submit a letter requesting termination indicating which site(s) to terminate & disposition of equipment or complete the RC-18R Radiation Machine Transfer & Disposal form. The letter or form must be signed and dated by the RSO

What is the process for terminating a registration?
The registrant will need to submit a completed RC- 17-R Termination of a Certificate of Registration indicating disposition of equipment. The form must be signed and dated by the RSO.

Laboratory Inspection Policies

General Information

The RSO or his designate will inspect all areas where radioactive materials are used or stored to ensure that safety requirements are being met. This will include following:

  • The proper posting of warning signs and the labeling of containers.
  • Confirming that the exposure levels do not exceed prescribed limits (2 mR/hr).
  • Verifying that the radioactive material is being used in accordance with the license, the proposal and/or directives of the RSO and University Safety Committee.

The RSO or his designate will regularly survey and/or wipe test any laboratories actively engaged in the use of radioactive material. More frequent wipes and/or surveys will be performed when:

  • The laboratory has a recent history of being contaminated; e.g., contamination is found in the laboratory for several consecutive months or contamination levels exceed 2 mR/hr.
  • The laboratory has a high potential of being contaminated; e.g., frequent handling of solutions of multi-millicurie amounts or the user is inexperienced and using multi-millicurie amounts.
  • The nature of a multi-millicurie procedure is unusual or inherently risky.
  • The RSO has determined that it should be done based on professional judgment.

Laboratory personnel shall perform additional surveys during procedures that could cause contamination or exposure concerns in addition to their routine in-process and post work surveys. The RSO should be contacted when any technical assistance is needed such as, during non-routine decontamination procedures.

Action Levels

Except for hoods and other enclosed areas not susceptible to the transfer of removable activity, Radiation Safety personnel will take action to have laboratory areas decontaminated if a wipe test exceeds 100 disintegrations per minute (dpm) beta/gamma or alpha activity averaged over 100 cm2.

Any contamination exceeding this limit will be highlighted on the lab map and delivered to the Principal Investigator as soon as practicable. Lab wipes that indicate levels of contamination 10 times the limit stated above are immediately made known to the Principal Investigator and the areas will wipe tested again by Radiation Safety personnel within seven working days. Radiation Safety personnel will provide technical assistance during any laboratory or personnel decontamination procedure, as necessary.

During laboratory surveys conducted by Radiation Safety personnel, any elevated radiation levels found that are not considered as low as reasonably achievable will be discussed with the PI and an attempt will be made to resolve the situation.

Laboratory Surveillance by Wipe Test

Any personnel performing a wipe test must wear disposable latex gloves. The wipe medium should consist of an absorbent paper measuring approximately 2.5 cm x 3.0 cm.
All wipe papers should be moistened with ethanol just prior to being used. Each wipe should represent a surface area as close to 100 cm2 as possible, but typically should be made in a random pattern over the general areas of interest.

Laboratory Surveillance with Portable Instrumentation

The Radiation Safety Officer or authorized delegate will oversee the surveying of the areas where the radioactive materials are stored and/or used, and provide the following technical support as needed:

  • A properly operating survey meter with a current calibration shall be used for surveys. The RSO will calibrate survey instruments at least annually and will arrange for prompt repair or replacement of inoperable or contaminated instruments.
  • The survey instrument’s audible switch should be turned “on” and “fast” response selected, if provided.
  • A close distance must be maintained between the probe and the surface being surveyed, about one centimeter, while avoiding potential probe contamination from contact with the surface.
  • While surveying, the detector must be moved slowly so that the instrument will have time to respond.
  • If any elevated radiation levels are found that are not considered normal, an attempt should be made to resolve the matter before leaving the laboratory.
  • After the survey, the instrument should be turned off, including the “audible” switch, if independently powered.

Personnel Monitoring and Dose Restrictions

The University is committed to the concept of personnel radiation exposures being as low as reasonably achievable (ALARA) and the following guidelines shall be observed:

Dose Restrictions for Radiation Workers

The radiation dose to minors and an embryo/fetus shall not exceed 10 percent of the limits stated below. The radiation dose to all other radiation workers shall not exceed an annual total effective dose equivalent of: 5 rem (0.05 Sievert) to the body; orn15 rem (0.15 Sievert) to the eye; or 50 rem (0.5 Sievert) shallow dose to the skin or any extremity.

In keeping with the ALARA policy, the RSO recommends that doses to radiation workers be limited to 10 percent of the dose limits described above. Any monitored individual exceeding these quarterly dose limits will be notified by RSO so that they may be able to modify their techniques to reduce their radiation exposure.

Declared pregnant workers may be occupational radiation workers provided that they follow all applicable personnel monitoring and dose restrictions outlined above, and ensure that assigned whole body dosimeter is worn at waist level at all times while at work.

Dose Restrictions to Individual Members of the Public

All operations involving the use of radiation shall be conducted in such a way to restrict the total effective dose equivalent to individual members of the public (non-radiation workers) as follows: 0.05 rem (0.5 millisievert) per year; or 2 mrem (0.02 millisievert) in any one hour.

Personnel Monitoring Policies

All personnel entering areas where a whole-body personnel dosimeter has been deemed to be appropriate shall wear the device in the position that will likely indicate the highest whole body dose (e.g., between chest and waist level, outside of clothing).

At a minimum, individual radiation dosimeters shall be worn by:

  • Adults likely to receive, in one year from sources external to the body, a dose in excess of 10 percent of the limits in TRCR, 25TAC 289.202(f)(1).
  • Minors likely to receive, in one year from sources of radiation external to the body, a deep dose equivalent in excess of 0.1 rem (1 mSv), a lens dose equivalent in excess of 0.15 rem (1.5 mSv), or a shallow dose equivalent to the skin or to the extremities in excess of 0.5 rem (5 mSv).
  • Declared pregnant women likely to receive during the entire pregnancy, from sources of radiation external to the body, a deep dose equivalent in excess of 0.1 rem (1 mSv).
  • Individuals entering a high or very high radiation area.

Personnel working with radioactive materials that are issued an extremity dosimeter (ring TLD), shall wear the dosimeter on a finger with the sensitive portion of the dosimeter toward the palm of their hand; i.e., closest to the source of radiation, so that the finger does not shield the dosimeter from the radiation. Those working with other sources of radiation; e.g., x-ray diffraction units, shall wear the ring dosimeter with the sensitive portion on their finger facing the radiation source. Ring dosimeters shall be worn under gloves when necessary to prevent device contamination. Radiation workers issued any type of personnel monitoring device, extremity or whole-body, shall not allow the assigned device to be worn by any other person.

Radiation workers will be issued a ring dosimeter on the following basis:

  • If the individual regularly handles millicurie amounts of energetic beta emitters or gamma/x-ray emitters (e.g., iodine-131); or
  • If the PI or radiation worker requests that a ring dosimeter be assigned, as long as the radiation source is detectable by the dosimeter; or
  • If the Radiation Safety Officer feels that extremity monitoring is warranted.

Radiological Emergency Procedures

General Information

In the event of an emergency involving radiation, special precautions must be taken to protect personnel. Items to be considered for use include coveralls, disposable gloves, disposable shoe covers, respirators, decontamination wash powder, radiation dosimeters, survey instruments, radiation signs, tags, labels, tongs, plastic bags, etc. Prompt notification to the RSO can expedite the arrival of needed equipment at the scene.

Notification Requirements

Requirements for the notification of incidents are located in 25TAC § 289.202(xx). Requirements for reporting exposures, radiation levels, and concentrations of radioactive material exceeding the limits are located in 25TAC § 289.202(yy).

RSO Notification

During business hours (9:00 a.m. to 5:00 p.m. work days), call the Radiation Safety Officer. After working hours, weekends or holidays, call the St. Mary’s Police. Provide the following minimal information: your name; building and location; description of the accident; type of radioactive material to be used; and estimated severity of incident/injury.

Stay on the line until all necessary information has been provided. If you called St. Mary’s University Police, they will notify the RSO and the appropriate emergency response personnel.

TDSHS Notification

After notifying the RSO/Safety Committee, the TDSHS, Radiation Control Program is required to be notified by telephone with confirmation within 24 hours of any incident involving any source of radiation, which may have caused or threatens to cause either of the following:

  • An individual to receive: a total effective dose equivalent of 25 rem (0.25 sievert) or more;
  • a lens dose equivalent of 75 rem (0.75 sievert) or more; or a shallow dose equivalent to the skin or extremities or a total organ dose equivalent exceeding 250 rad (2.5 grays) or more.

The release of radioactive material, inside or outside of a restricted area, so that, had an individual been present for 24 hours, the individual could have received an intake in excess of five (5) times the occupational annual limit on intake (ALI). This provision does not apply to locations where personnel are not normally stationed during routine operations, such as hot-cells or process enclosures.

Twenty-four hour notification to the TDSHS, Radiation Control Program is required initially with confirmation within 24 hours of any incident involving any source of radiation, which may have caused or threatens to cause:

  • An individual to receive, in a period of 24 hours: a total effective dose equivalent exceeding 5 rem (0.05 sievert);
  • a lens dose equivalent exceeding 15 rem (0.15 sievert);
  • or a shallow dose equivalent to the skin or extremities or a total organ dose equivalent exceeding 50 rem (0.5 sievert).

The release of radioactive material, inside or outside of a restricted area, so that, had an individual been present for 24 hours, the individual could have received an intake in excess of one (1) occupational annual limit on intake (ALI). This provision does not apply to locations where personnel are not normally stationed during routine operations, such as hot-cells or process enclosures. In the event of a radiation incident, the procedures outlined in the following section shall be followed immediately.

Radioactive Material Spills and Contamination

Radioactivity cannot be destroyed by chemical or physical means. Decontamination, therefore, must depend upon the removal of the radioactive material. Removal of contaminants falls into two general methods, physical or chemical removal. It can be further divided into the removal from personnel and from materials or areas.

Any area is considered contaminated if removable activity is at a level greater than 1000 disintegrations per minute (beta, gamma) per 100 cm2. Every effort should be made to prevent the spread of contamination during decontamination.

Contamination/Exposure Control for Localized, Non-volatile liquid Spills

When liquid radioactive material is spilled, specific action must be taken. Listed below, in order of priority, are steps to be taken in handling a spill of this nature:

  • Request help from lab workers, if available.
  • Make a quick evaluation of the extent of the airborne potential – If there is potential for an airborne problem, shut off the air handling system and leave the immediate area, keep involved personnel in the general area, prevent the entry of non-essential personnel, and contact the RSO.
  • If there is no airborne potential, proceed to monitor personnel and the area to establish the extent of the contamination. If the radiation levels in the area exceed two millirem per hour, shield the source or leave the area.
  • Control the area. Avoid the spread of contamination. If your shoes are contaminated and you must leave the area, go to the outer perimeter of the contaminated area and remove your shoes, rope off the area, and post signs warning of the radiation incident. Avoid leaving the area unattended or unlocked.
  • Notify the RSO of the spill. Provide general details and the location of the incident. Maintain control of the area.

Contamination/Exposure Control for Powdered, Volatile Liquid or Gaseous Spills

  • Turn off ignition sources and air handling equipment, if possible.
  • Evacuate the area immediately.
  • Assemble personnel immediately outside the room and instruct them to stay in one location, to prevent the spread of contamination.
  • Close and lock the room doors to prevent re-entry.
  • Attempt to seal accessible openings into the laboratory to prevent further escape of airborne activity to outside areas.


Decontamination of any workers involved in a major incident must be performed under the supervision of Radiation Safety personnel, if possible. Skin should be decontaminated immediately and contaminated clothing should be promptly removed. Skin and clothing contamination shall be reported to the Radiation Safety Officer so a determination can be made if the quantities exceed one-tenth of the quantities listed in TRCR, 25TAC § 289.202(f)(1).

Decontamination of the area should begin as soon as possible, but after personal injuries are taken care of. Because St. Mary’s does not currently have staff trained in decontamination, the affected area should be cordoned off for restricted access, and a qualified contractor should be contacted as soon as possible for cleanup, decontamination, and subsequent monitoring.

Care of Injured Personnel

If a person is both injured and contaminated, a quick decision will have to be made as to the best possible course to follow. An appropriate course of action should be:

  • Apply first aid, if necessary, using caution not to further aggravate the injury. Do not totally disregard the radioactive contamination, but it should be secondary to caring for the injured person; the contamination can be dealt with at a later time.
  • If a radiation worker sustains a serious injury or illness that requires emergency medical treatment, immediately contact St. Mary’s University Police and request an ambulance. When the ambulance arrives, notify the paramedics of the extent of physical injury and the potential for radiation contamination. The paramedics will determine the appropriate level of additional treatment required before transporting the patient to the hospital.
  • If a radiation worker sustains a minor injury and requires non-urgent medical treatment, the worker must immediately report the accident to the PI, supervisor, or the designated department head who will immediately report the accident to the RSO. If necessary, the PI or supervisor should escort the injured worker to the emergency facility or clinic.
  • In all emergencies, the RSO should be contacted after first aid has been administered and the appropriate medical personnel have been contacted. Once the RSO arrives on the scene of accident, he will evaluate the extent and severity of the contamination.

Care of Contaminated/Exposed Personnel

Radiation Safety personnel will evaluate the extent of all potential personnel exposures. If necessary, arrangements will be made for the exposed person to go to an appropriate facility for examination to determine the extent of any radiation dose and/or treatment.

In determining the severity of the injury contamination, the following factors must be considered:

  • External contamination is not immediately harmful to the patient unless their skin is badly punctured or wet.
  • All but a very few of the most serious accident cases can be treated successfully by medical personnel at the scene.
  • The contamination of the individual may be harmful to other people if it is spread to the ambulance and the emergency room.

All cuts that penetrate the skin offer a point of easy access to the body for radioactive materials. Radioactive material should not be allowed to contact a cut anywhere on the body. If a contaminated article cuts a person, the wound should receive immediate treatment. It should first be cleansed very thoroughly with soap and water. Free bleeding should then be checked for contamination if a high-energy beta or gamma emitter is known to be involved. Soft beta and gamma emitters cannot be easily detected in a cut, particularly in the presence of water. All cuts involving possible contamination should be reported to the RSO so that necessary steps can be taken immediately to evaluate the contamination.

Proposal to use Radioactive Materials

Instructions: The Principal Investigator (PI) must complete this document and forward it his/her Department Chairperson for approval. Once the Department Chairperson approves this proposal, the chairperson shall send it to the University Radiation Safety Officer. The Radiation Safety Officer will review this proposal and then present it for approval to the St. Mary’s University Safety Committee. This proposal must be approved by the RSO and the University Safety Committee prior to initial use of radioactive material on campus.

  • Attach to this proposal a copy of the PI’s most recent curriculum vitae. CV should list training and experience related to the use of radioactive material.
  • Provide detailed description of any training and experience related to the use of radioactive material that is not listed in the PI’s CV.
  • Name of all personnel that will be using the radioactive material?
  • Where will the radioactive material be used (building, room number)?
  • How long do you anticipate this project will require (ongoing, months, years)?
  • What equipment (laboratories, hoods, sinks, storage facilities, etc.) is required for this project?
  • Provide a detailed description of this project.
  • List radioactive material that will be used in this project.
  • Where and how will the radioactive material be stored?
  • What safety measures will be provided to ensure users are not exposed to excessive amounts of radiation?
  • Where will the radioactive material warning signs and/or labels be posted?
  • Will personnel dosimeters be required? Yes                  No
  • What emergency procedures will be taken if an accident should occur?
  • What type of radiation detection equipment will be used?
  • What security measures will be followed?

Radioactive Material Inventory Report

Instructions: Each Principal Investigator that uses radioactive material (licensed and exempt) is required to keep an inventory of radioactive materials in their possession. Inventory reports should be submitted annually to the RSO at the beginning of the fiscal year (June 1). 
The activity of a radioactive source at any time can be determined from where A(t) is the activity at time t, A0 is the initial activity, t is the elapsed time since initial activity, and T1/2 is the half-life of the radionuclide. Note that T1/2 and t must be in the same units.

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