2006 Rad Safe Forms
1
Form 1
Date:
Name:
Title:
Office:
Phone Office:
Home:
STATEMENT OF TRAINING
Dept.:
(Bldg. / Room)
RADIATION TRAINING SUMMARY:
Course Work:
Course Name
and Number
Dates of
Instruction
Course Content and Instructor
Work Related Experience:
Place of Experience
Dates
Experience and Isotopes Used
(Use additional pages if necessary)
(Signature) _________________________________
Form 1: 8/6/93; revised 1/1/94, 3/13/95,12/12/00, and 7/15/06
Form 2
STATEMENT OF AGREEMENT
The below named individual signifies that she/he has read the Minnesota State University
Moorhead policy, has read and has a copy of the Minnesota State University Moorhead
radiation safety handbook, and is willing to abide by the Minnesota State University Moorhead
regulations concerned with the safe handling, use, and disposal of radioisotopes on campus,
following the rules of the Minnesota State University Moorhead ALARA program.
The below named person agrees to attend the radiation safety training and refresher courses as
required by the Minnesota State University Moorhead Radiation Safety Program as a prerequisite
for authorization for use of radioisotopes as research and instructional aids. The below named
person, in further compliance with these regulations, agrees to wear a film badge or other
prescribed personnel monitoring devices, during all periods of usage of beta emitters with
energies of greater than 1 MeV and all gamma emitters of 1 millicurie.
The undersigned also agrees to comply strictly with all rules and regulations issued governing the
use of radioisotopes and hereby waives any right to recourse against the university, the RSO and
the RSC for any damages whatsoever resulting from any failure to fully conform with such rules
and regulations.
The below named individual also agrees to report any known instances of noncompliance to
his/her principal investigator, and/or to the RSO and the RSC. The below named individual also
realizes that if he/she is found to be in non-compliance with the regulations outlined in the
Minnesota State University Moorhead program, and that investigation demonstrates continued
non-compliance, that that person's authorization to use radioisotopes may be revoked by the
RSO until further training and/or willingness to comply with the regulations of the ALARA program
are demonstrated.
The below named individual has taken and passed with a 75% the Radiation Safety Test
Date of test___________ RSO Initial ________
The below has watched or participated in the MSUM short course (on-line or in person) AND has
been through a personal orientation with the RSO or their Principle investigator. This personal
orientation must have included the following:
o
o
o
o
o
o
Signed:
Tour / Review of site
Answer any remaining questions
Key & SL 222 (storage and main room) access
Completed Forms 1 and 2
Wipe Test / Survey Review
Web site and Handbook Review
Date:
Form 2: 8/6/93; revised 1/1/94, 3/13/95 12/12/00, and 7/15/06
Form 3. REQUEST FOR PERMISSION TO POSSESS AND USE RADIOISOTOPES OR IONIZING RADIATION
PRODUCING DEVICES
1.
Names1 of all persons who will be in contact with isotope:
_______________________________________________________Dept.___________________________
_______________________________________________________Dept.___________________________
2. _________________________ 3. ____________________________4. _________________________
(Isotope)
(Chemical Form)
(Quantity)
1. ______________________________________
6. ___________________________
(Catalog Number and Supplier)
(Date Desired)
7.
Location of Use2 _____________________________________________________
(Building)
(Room No.)
8.
Proposed use3 _______________________________________________________________________
_____________________________________________________________________________________
_
9.
Safety Precautions and Personnel Monitoring Required4
______________________________________________________________________________________
_____________________________________________________________________________________
_
10.
Waste Disposal Procedures5
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
11.
12.
Signed:
This isotope (will) (will not) be used in or on human beings.
This isotope (will) (will not) be used in or on animal subjects.
____________________________________________________________
(Licensed Principal Investigator)
____________________________________________________________
(Title)
(Date)
---------------------------------------------------------------------Approved (prior to) (after) Committee action
1
2
3
(RSC): _________________________________ (RSO): __________________________________________
Approved (prior to) (after) Committee action
Committee Action: ______________________________ Date:________________
All persons whose names appear here must provide a written statement of training in radioisotopes
techniques and sign the state of agreement form.
For areas of usage not already approved by the Committee, a complete description of facilities
and equipment to be used in these studies must be attached. All areas outside of SL 222
radioisotope laboratory must be approved prior to utilization by the Radiation Safety Committee.
A complete description of the experimental procedures should be on file with this application. This
description should include an outline of the experimental procedures, justification for the use of
radioisotopes for this application, safety precautions and personnel monitoring which will be
conducted by personnel using this radioisotope, a description of survey procedures which will be
conducted in the laboratory while these isotopes are being used, and waste disposal procedures.
Form 3: 8/6/93; revised 1/1/94, 3/13/95 12/12/00, and 7/15/06
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In all descriptions, it should be demonstrated that ALARA principles will be used in the handling and
utilization of this radioisotope.
5 See comment #4
See comment #3.
Form 3: 8/6/93; revised 1/1/94, 3/13/95 and 12/12/00
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Form 4
REQUEST FOR ORDERING AND STORAGE OF RADIOISOTOPES OR IONIZING RADIATION
PRODUCING DEVICES
Date: _____________________
For: ______________________________________ Dept.____________________
Project Title: ______________________________________________________
Grant Number, Title and Agency:______________________________________
To be used in Room(s): __________ To be stored in Room ______________
Isotope: ________________________ Chemical Form: ____________________
Quantity: _______________________ (Becquerels or mBecquerels)
Concentration: _____________ (Bq/ml) Volume: ______________________ml.
Specific Activity _________________________ (Bq/g; Bq/umole)
Assayed at
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Assay Method
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Total Solids: ___________ mg/ml; Normality: __________; pH: ________
Supplier: _______________________________: P.O. No. _________________
Additional Information:____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________________________________________________
Intensity of Radiation at surface of Shield ________________mrem/hr.
Completed by: _______________________________________________________
* * * * * * * * * * * * * * * * * * * * * * * *
Surveys of material at time of receipt:
Background counts: __________; Outside of package: ____________;
Outside of container: ___________; Other: _____________________.
Accept Reject Shipment: _____________________________________________
(Signature)
The original copy of this form shall be held on file in the working laboratory to enable the laboratory
director to know the quantity and type of radiomaterials present in his/her laboratory at any given
time. After receipt of material and usage has begun, the detailed inventory of material should be
kept on Form 6. Radioisotope Inventory and Utilization Log.
A duplicate copy of this form shall be maintained in the utilization file and this file stored along with
other radioisotope data at the central storage area supervised by the RSO and the RSC.
Form 4: 8/6/93; revised 1/1/94, 3/13/95 12/12/00, and 7/15/06
Form 5: REQUEST FOR PERSONAL MONITORING DEVICE(S)
Date:
For:
; Dept.
Principal Investigator:
Project Title:
Type of Personal Monitor:
Amount, Type and Chemical Form of Radioisotope or Ionizing Radiation Producing Device to be
Used by Individual Requesting Personal Monitor:
Date that monitor is needed:
Expected dates during which monitor will be needed:
Grant Number, Title and Agency:
Principal Investigator
(Signature)
Radiation Safety Officer:
(Signature)
Form 5: 8/6/93; revised 1/1/94; 3/13/95, 8/4/95 and 12/12/00
Form 6.
RADIOISOTOPE INVENTORY AND UTILIZATION LOG
Radioisotope:
Chemical Form:
Received:
; Date Ordered
Catalog Number
; Serial Number:
Amount of material received:
Specific radioactivity:
(Bq or mBq);
(Bq/mmole or Bq/umole)
Principal Investigator Who Ordered Material:
Receipt Surveys conducted by:
Outside of box:
Date
Inner Packing:
User
Outside of Vial:
Other: ________
Purpose
Amount
Used
8/6/93; revised 1/1/94; 3/13/95, 8/4/95 and 12/12/00
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Amount Remaining
Form 7.
DECLARED PREGNANT WOMAN STATEMENT
The below named individual signified that she has read the radiation safety information for the
embryo/fetus, has discussed that information with her principal investigator and the RSO, and
accepts her risks and responsibilities for making the decision to continue working with
radioactive materials during the pregnancy. The individual becomes a declared pregnant
woman with the date and signature given below, and also gives the estimated time of
conception and the estimated time of parturition. This information will be kept in complete
confidence and is only used to calculate the potential radiation exposure to the embryo/fetus
during the 9 month period and to maintain that exposure below the 0.5 rem limit for the
gestational period.
Date Pregnancy was Declared to RSO:
Date of Instruction on Risks to Embryo/Fetus:
Instructional Information Provided Prior to Making this Decision:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Estimated Date of Conception:
Estimated Date of Parturition:
Do you plan to continue working with radioisotopes in a research/instructional capacity?
____________________________________
Signature:
Principal Investigator:
(Signature)
Radiation Safety Officer:
(Signature)
Form 9.
Wipe Test Analysis
Date____________ Name________________
Wipes will be taken once each week in the designated areas ( see attached map) of Science Lab
222, except during weeks in which no radioisotopes are used nor waste handling/disposal is
conducted. DPM will be determined using the Beckman LS 3801 liquid scintillation counter. Counts
will be done using the appropriate channel(s) for the isotope(s) which was (were) used during that
week; counts will be conducted a minimum of 5 minutes/count. Wipes will be taken with water
moistened filter paper or cotton swabs, wiping a 100 cm2 area, and placed in a vial with an
appropriate volume of water-soluble liquid scintillation cocktail (5.0 ml for the small vials). Wipe
results of greater than 3X background counts will indicate the need for re-washing and reassessment of the area. Any additional areas (based on use) will also be wiped. Additional wipes
will be marked on the map with a number indicating the area and the resulting counts included
below. If additional wipes are needed, Simply re-number this form for your needs and not the
activity and reason on an attached page. All counts are to be stored in the log.
Area
1
DPM
Avg Background Counts:__________
Area
DPM
Area
21
41
2
22
42
3
23
43
4
24
44
5
25
45
6
26
46
7
27
47
8
28
48
9
29
49
10
30
50
11
31
51
12
32
52
13
33
53
14
34
54
15
35
55
16
36
56
17
37
57
18
38
58
19
39
59
20
40
60
DPM
Describe action taken if any of the areas tested were above the acceptable radiation limits.
Include a second wipe test analysis of the areas following this action.
8/6/93; revised 20/07/06
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Form 10
Radioactive Waste Disposal
Date: _____________
Authorized User: ______________________________________________________.
(Signature)
Radioisotope: ______________ Chemical Form: _________________________.
Aqueous Waste Disposal1:
Volume: _____________ Amount: ______________ (Becquerel or µCi).
Concentration of radionuclide: ________________ (µCi/gm or Bq/gm).
Location of Disposal: __________________________________________.
Solid Waste Disposal2:
Amount: _________________________________(Becquerel or µCi)
Shipped to Disposal Site: _____ or Stored on Site ___________
Location of Disposal Site:_______________________________________.
Scintillation Cocktail Waste3:
Volume: ____________; Amount: __________________(Becquerel or µCi).
Concentration of Radionuclide: ___________________(µCi/gm or Bq/gm)
Location of Disposal: ____________________________________________.
Additional Description of Disposal Activities:
************************************
1.
One sink should be designated for aqueous waste disposal in each restricted facility.
Each time a container is disposed, one of these forms must be filled out and kept on file
with the principal investigator. It is suggested that a duplicate copy be placed on file in
central storage. Records of aqueous waste disposals must be kept for three years.
2.
All solid waste must be given to the RSO for disposal. No solid waste will be disposed by
anyone other than the RSO.
3.
0.05 microcurie (1.85 kBq), or less, or tritium or carbon-14 per gram of medium used for
liquid scintillation cocktail may be disposed of as aqueous, nonradioactive, waste,
providing the cocktail is a grade which is sewerable. If not a sewerable cocktail, the
cocktail must be disposed of as organic waste. Again, records of these disposals must be
made on this form, one copy kept on file by the principal investigator while a second
copy is placed in central storage. Non-aqueous waste must be reported to the university
chemical hygiene officer for proper disposal.
8/6/93; revised 20/07/06
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PROCEDURES FOR THE SAFE HANDLING AND USE OF RADIOACTIVE BYPRODUCT MATERIALS AND IONIZING RADIATION PRODUCING
DEVICES TO MAINTAIN EXPOSURE LEVELS "ALARA."
Radiation Safety Officer: Joseph J Provost
Office -- 477-5085; Home-- 271-0537
Radiation Safety Chair: Judith Strong
Office -- 477-2075
Radiation Safety Committee Members:
Mark Wallert
Chris Chastain
1.
While performing experiments with radioisotopes, the experimenter is not to engage in
eating, drinking, smoking or applying cosmetics.
2.
Protective clothing (lab coats) should be worn while performing experiments using
radioisotopes. All protective clothing worn while performing experiments with
radioisotopes in the laboratory is to be left in the radioisotope laboratory.
3.
All persons working with radioisotopes are to wear disposable gloves at all times while
working with these materials. These gloves must be disposed of in the designated
container at the end of each experiment.
4.
After completion of experimentation, a survey of the working area and person (if
applicable) is to be made by wipe testing. If detectable amounts of radioisotopes are
found, the area is to be washed thoroughly until surveys demonstrate that levels have
been decreased to less than 3X background counts. A record should be kept of each of
these washes and surveys, wash solutions are to be treated as aqueous, sewerable waste
and should be monitored and the disposal documented on Form 11: Radioactive
Waste Disposal.
5.
If surveys of experiment areas reveal counts of 5X background counts or greater, the
Radiation Safety Officer should be contacted to assist with the decontamination.
6.
All radioactive wastes are to be disposed of according to approved waste disposal
procedures. All sewerable waste is to be documented on Form 11: Radioactive Waste
Disposal in the designated disposal sink, only.
7.
Thorough hand-washing must be done at the end of each experiment using
radioisotopes, as should be done upon completion of any chemistry or biology
experiment.
8.
Apparatus and glassware used in radioactive experimentation and used in the
radioisotope laboratory are not to be transported into non-restricted areas.
9.
All incidents, including spills and incidents are to be immediately reported to the
principal investigator and to the RSO. The procedures for incidents and spills involving
radioactive materials must be followed when working with these materials.
10.
If you have any questions, wish to report incidents or wish to report incidents of noncompliance with the Minnesota State University Moorhead radiation safety program,
contact the Radiation Safety Officer or other members of the Radiation Safety
Committee.
8/6/93; revised 20/07/06
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