Radiation Safety Manual
Environmental Health and Risk Management Department
2010
UNIVERSITY OF HOUSTON
Radiation Safety Manual
TABLE OF CONTENTS
¾ Preface
¾ Emergency Numbers and Helpful Information
¾ Radiation Safety Program
GENERAL
¾ Radiation Safety Training Requirements
¾ Personnel Monitoring Procedures and Guidelines
¾ Radiation Safety Guidelines for Radiation Facilities Changes and
Services
¾ Respiratory Protection
RADIOACTIVE MATERIAL
¾ Radioactive Material Sublicense Application and Amendment
Guidelines
¾ Receipt, Package Check-In, Inventory Number, Record of Use,
Transfer & Lab Storage Procedures
¾ Radioactive Material Procurement Procedures
¾ Radioactive Material Laboratory Setup Guidelines
¾ Radioactive Material Laboratory Safety Guidelines
¾ Radioactive Material Laboratory Survey and Wipe Test Procedures
¾ Radiation Safety Procedures for the Use of Radioactive Material in
Animals
¾ Radioactive Waste Disposal Procedures
¾ Radiation Spill, Accident, Decontamination, and Emergency
Procedures
X-RAY MACHINES & OTHER IONIZING RADIATION PRODUCING
DEVICES
¾ Subregistration and Amendment Application Guidelines
¾ Procurement Procedures
¾ Receipt, Setup, Documents, and Use
¾ Radiation Safety Requirements for the 1.7 MeV Particle Accelerator
¾ Basic X-ray Safety Guidelines
¾ Radiation Safety Requirements for Analytical X-ray Equipment and
Other Registerable Analytical Ionizing Radiation Producing Devices
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¾ Radiation Safety Requirements for X-ray Machines in the Healing
Arts
¾ Radiation Safety Requirements for X-ray Machines in Veterinary
Medicine
LASERS
¾
¾
¾
¾
¾
Lasers Subregistration and Amendment Application Guidelines
Laser Procurement Procedures
Radiation Safety Requirements for Lasers
Basic Laser Safety Guidelines
Laser Receipt, Setup, Documents, and Use Guidelines
GLOSSARY OF TERMS
RADIATION SAFETY FORMS
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Radiation Safety Manual
Pref ace The objective of the Radiation Safety Program is to assist all levels of management
in fulfilling the commitment at the University of Houston to provide a place of
employment and learning which is as free as possible from recognized radiation
hazards.
The purpose of the Radiation Safety Manual is to assist personnel, students, and
management in complying with the State Radiation Regulations and the Radiation
Safety Program.
This Radiation Safety Manual is not intended to be an exhaustive or fully
comprehensive reference, but rather a guide for Principal Investigators and
Authorized Users. Further advice concerning hazards associated with specific
radioactive material, radiation producing devices, and/or the development of new
or unfamiliar procedures should be obtained through consultation with the
Radiation Safety Officer.
The Radiation Safety Manual is an enforceable component of the Radioactive
Material Broad Scope License and Radiation Producing Devices Registrations
under which the University of Houston is authorized.
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Emergency Telephone Numbers and Inf ormation Environmental Health and Risk Management
( 7 1 3 ) 7 43 - 5 8 5 8
Environmental Health and Risk Management (Fax)
(713) 743-8035
Radiation Safety Officer
(713) 743-5867
Health Physicist (Radioactive Materials)
(713) 743-5870
Health Physicist (X-ray Machines and Lasers)
( 7 1 3 ) 7 4 3 -5 8 6 0
University Health Center
(713) 743-5151
University of Houston Police Department (Emergency)
(713) 743-3333
University of Houston Police Department (Non-Emergency)
(713) 743-0600
Medical Emergencies
911
Environmental Health and Risk Management office hours are Mondays through
Fridays, 8:00 a.m.-5:00 p.m.
For assistance with a radiation emergency or incident during normal office hours
call Environmental Health and Risk Management.
In the event of an after-hours radiation emergency, contact the University of
Houston Police at the Department of Public Safety. Environmental Health and
Risk Management maintains an on-call mechanism to provide expertise in the
event of an after-hours situation requiring assistance.
Radioactive material spills and emergency information is available in the Radiation
Safety Manual at http://www.uh.edu/plantops/ehrm/ehrm_manuals_radsafety.html
If you call after normal office hours about a non-emergency incident, you may
leave pertinent information on Environmental Health and Risk Management’s
telephone voicemail system and your call will be returned later.
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Radiation Safety Manual
Radiation Safety Program The University of Houston is authorized by the Texas Department of State Health
Services (TDSHS) to receive, acquire, possess and transfer certain radioactive
materials and sources of radiation to further its mission of research and education.
The License and Registration conditions require strict control of the use of
radiation producing devices and radionuclides to ensure that radiation exposures to
all authorized users and members of the public are kept as low as reasonably
achievable.
The Radiation Safety Program is designed to provide adequate safeguards to the
health and well being of the University of Houston community and the communityat-large from the potentially harmful effects of radiation. This is accomplished by
maintaining compliance with applicable Federal, State, and University regulations
and through the establishment of good health physics work practices at the
University of Houston.
The Radiation Safety Program applies to all persons who purchase, possess,
transfer, store, use, or handle radioactive material in any amount, licensed or
unlicensed, and/or radiation producing devices, registered or unregistered, at the
University of Houston.
The University of Houston requires that all users of radioactive material or
radiation producing devices on the campus receive radiation safety training, be
approved by the Radiation Safety Officer and authorized by the Radiation Safety
Committee, and, comply with applicable regulatory requirements to ensure that
radiation exposure levels are kept ALARA, “As Low As Reasonably Achievable”.
Responsibility for implementing the Radiation Safety Program to maintain the
license and registration is delegated appropriately within the campus. The
organization of the UH Radiation Safety Program includes the Radiation Safety
Committee, Radiation Safety Manager/Radiation Safety Officer, Radiation Safety
Staff, Principal Investigators and Authorized users. The Radiation Safety Program
Office is staffed by the Radiation Safety Manager/Radiation Safety Officer, two
Laboratory Safety Officers with specialization in Health Physics, and supported by
an Environmental Protection Specialist.
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Radiation Safety Committee The Radiation Safety Committee is charged with ensuring that the University of
Houston’s Radiation Safety Program remains in compliance with the State
Radiation Regulations, Title 25 of the Texas Administrative Code, Chapter 289.
The Radiation Safety Committee advises the UH administration including the
President, the Executive Vice President for Administration and Finance, the Senior
Vice President for Academic Affairs and Provost, and the Vice President for
Research about radiation hazards at the University of Houston. The Radiation
Safety Committee functionally operates under the authority of the Vice President
for Research and has the responsibility of assuring radiation safety at the
University of Houston.
The Texas Department of State Health Services granted the University of Houston
a Radioactive Material Broad Scope License in 1972 and subsequent X-ray and
Laser Registrations. As required by the license and registrations conditions, a
Radiation Safety Committee was appointed to formulate policies and procedures
relating to radiation safety. Specifically, the Committee works with the Radiation
Safety Officer to:
‰
Review and grant permission for, or disapproval of, the use of radioactive
material and/or radiation producing devices including lasers and x-ray machines
at the University of Houston.
‰
Review and prescribe special conditions, requirements and restrictions as may
be necessary to protect University of Houston faculty, staff and students, and
the general population from health hazards associated with radioactive material
and radiation producing devices at the University of Houston.
‰
Prepare and disseminate information on radiation safety and provide training in
the use of and requirements pertaining to radioactive material and radiation
producing devices at the University of Houston for the instruction and guidance
of the faculty, staff, and students.
‰
Approve in advance, all structures and laboratories in which the use of
radioactive material or radiation producing devices is planned including new
construction and modifications to existing facilities.
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Radiation Safety Manual
‰
Provide additional technical expertise to the Radiation Safety Program. Review
and support the Radiation Safety Program and assist with solutions to issues
arising from the use of radioactive material and radiation producing devices.
‰
Shutdown or order the immediate cessation of work in any facility where it is
evident that health hazards exist and/or that operation is in violation of existing
federal, state, and city regulations.
‰
Investigate any possible misuse, apply and enforce any necessary disciplinary
action, and notify the Texas Department of State Health Services of any
reportable incidents.
Radiation Safety Staff Radiation Safety Staff acts as the operational functionary for the Radiation Safety
Committee and the University community. The Radiation Safety Officer is
responsible for implementing all parts of the Radiation Safety Program,
maintaining regulatory compliance, and establishing good health physics work
practices at the University of Houston.
Specifically, the Radiation Safety Officer will:
‰
Work with the Radiation Safety Committee to develop policies and
procedures for the protection of all individuals from the potential hazards
related to radiation emitting material, machines, or waste.
‰
Advise the Radiation Safety Committee about radiation hazards, make
recommendations for the approval or disapproval of new facilities and/or
Principal Investigators, and provide the signage and postings for radiation
laboratories.
‰
Disseminate information on radiation safety protection and provide specific
radiation safety training courses.
‰
Administer the University of Houston's Broad License, X-ray Registration,
and Laser Registration with the Texas Department of State Health Services.
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‰
Inspect all University of Houston’s laboratory facilities using radioactive
material or radiation producing equipment to ensure safe use and compliance
with the State Radiation Regulations.
‰
Provide a current and comprehensive Radiation Safety Program for the
University of Houston and maintain all required records.
‰
Provide health physics services and consultative technical support to faculty,
staff, and students.
‰
Perform investigations and report incidents to the Texas Department of State
Health Services.
Principal Investigators Principal Investigators are specifically authorized by the Radiation Safety
Committee to obtain and use radioactive material and/or radiation producing
equipment at specified locations within the University. Principal Investigators are
responsible for all parts and conditions of their sublicenses or subregistrations, the
training and safety of their Authorized Users, and their compliance with all
applicable regulations.
Authorized Users Authorized users are specifically approved to work with radioactive material
and/or radiation producing equipment under the sublicenses and/or subregistrations
of their Principal Investigators. Authorized Users are responsible for working
safely with radioactive material and/or radiation producing equipment which they
are approved for, and for complying with all applicable regulations.
General Laboratory Workers General Laboratory workers are non-radiation laboratory workers in radiation
laboratories. They should be properly educated by the Principal Investigators or
Laboratory Safety Manager in radiation safety awareness in the laboratories.
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Radiation Safety Training Requirements Training and education is a primary means of achieving a safe and healthy working
environment. The mandatory radiation safety training provides fundamental
principles of radiation protection and safety guidelines to all authorized users of
radioactive materials and radiation producing devices.
The Radiation Safety Committee requires all users of radioactive material, Class
IIIb and IV lasers, X-ray machines, and other ionizing radiation producing devices
requiring registration to attend and pass the applicable radiation safety course.
This includes all Authorized Users and Principal Investigators.
The Radioactive Material, X-ray, and Laser Safety courses are currently offered
with an exam requiring at least 70% for passing. A certificate is issued to all who
attend and pass. Failure to pass the course will require that a participant review the
handout material and the Online Radiation Safety Manual and then retest within
one month. Failure to pass the course will lead to suspension from working with
any source of radiation.
The three courses are taught at least once a semester. Notices of training are sent to
Principal Investigators. Other interested faculty, staff, and students are welcome to
attend. Class registration is available by calling the EHRM at 713-743-5858 or at
http://www.uh.edu/plantops/ehrm/ehrm_training.html .
Warning: Completion of a radiation safety course does not automatically
make you an Authorized User. To work with specific radioactive material and/or
radiation producing devices as an Authorized User, you must be added to a
Principal Investigator's sublicense or subregistration through an amendment
application.
Annual on-line Radiation Safety Refresher Training courses must be completed
within each calendar year by all persons authorized to work with Radioactive
materials, X-rays machines and Class IIIb and IV Lasers. Principal Investigators
and Authorized users will receive a notification of required refresher training.
There is an exam with the refresher training with a required minimum grade of
80% for passing. The RSO will notify participants by email of either passing or
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failing the exam. Failure to pass the refresher training will require that a
participant review the training presentation and then retest within one month. The
participant may also review the Online Radiation Safety Manual and Radiation
Safety personnel may be contacted for assistance. There is no penalty for multiple
attempts. Non-completion of the refresher training, either by not taking or passing
will lead to suspension from working with any source of radiation.
Conditional approval as an Authorized User may be granted by the RSO to an
applicant, prior to completing the full course due to working demands, if they:
• provide documentation of adequate radiation safety training and experience
or,
• successfully complete the applicable radiation safety refresher training
course.
Conditional approval, when granted is temporary until the full course is completed.
Approval will be revoked if the full course is not completed as scheduled.
Adherence to all Radiation Safety Manual procedures is required.
Principal Investigators are also required to provide protocol specific on-the-job
training to their Authorized Users regarding the safe use of radioisotopes and /or
radiation equipment in their laboratories. Radiation workers who do not receive the
required training should contact the Radiation Safety Officer at 713-743-5867 for
assistance.
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Personnel Monitoring Procedures and Guidelines Radiation dosimetry involves the estimation of the absorbed dose resulting from
the exposure to indirectly and directly ionizing radiation. Use of personnel
dosimeters ensures that we are following the principle of ALARA, keeping
exposures as low as reasonably achievable. The Radiation Dosimetry Program is
administered within the Radiation Safety Program and includes both internal and
external exposures.
Radiation badges/monitors are only required to be issued to radiation workers
likely to receive one-tenth of the maximum permissible exposure limits, but this
exposure level is generally unlikely at UH labs. Badges are still issued to users of
larger amounts of high energy beta and gamma emitters, as well as the primary
users of x-ray diffraction machines and particle accelerator. Area badges are
located in or around potentially higher exposure laboratories for Public Dose
Monitoring.
Radiation badges are issued on a quarterly basis and all monitoring records are
kept by the Radiation Safety Officer at the Environmental Health and Risk
Management Department. Any unusual or high doses are investigated and the
participant is notified as required. These records are available for review at the
above location. The investigation level of the "As Low As Reasonably Achievable"
(ALARA) program is set at one-tenth of the maximum permissible exposure limits
(See occupational exposure limits below).
Radiation workers that may require radiation badges must fill out a Radiation
Badge Request Form and send it to EHRM-1005. All forms can be found in the
UH Radiation Safety Manual at http://www.uh.edu/plantops/ehrm/ehrm_ training.
html
UH Pregnancy Brochure A pregnant radiation worker who wants to work at the lower fetal dose is required
by law to voluntarily declare, in writing, to her employer of her pregnancy and give
the estimated date of conception. This is accomplished via the Radiation Safety
Officer at the University of Houston. A monthly fetal film badge will be issued to
be worn at the waist and the dose will be monitored during the entire pregnancy as
stipulated in the State Radiation Regulations. A pregnant radiation worker may
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undeclare the declaration, in writing, to her employer at any time during the
pregnancy without explanation. More information on pregnancy declaration,
undeclaration and associated forms can be found in the forms section of this
manual. Further information on radiation protection during pregnancy is provided
in the UH Pregnancy Literature and INSTRUCTION CONCERNING PRENATAL
RADIATION EXPOSURE.
Occupational Maximum Permissible Exposure Limits Current dose limits for occupational radiation exposure as specified in regulations
are based upon the conservative assumption that there is no safe level of exposure.
This assumption has led to the general philosophy of not only keeping personnel
doses below recommended levels or regulatory limits but of also maintaining all
doses "as low as is reasonably achievable" (ALARA). This is a fundamental tenet
of current radiation safety practice.
The limits are:
Whole Body
Any individual organ or tissue
Eye
Skin or extremity
Minor (Under 18 years old)
Individual member of public
Embryo/Fetus (During entire pregnancy)
5 rem/year
50 rem/year
15 rem/year
50 rem/year
10% of above limits
0.1 rem/year
0.5 rem/10 months
The radiation badge should be worn during working hours, and only during
working hours. When not in use, badges should be kept in a location away from
radiation. The radiation badge should never be taken home or left in a car.
If a badge is lost, damaged or contaminated, notify the Radiation Safety Officer
immediately and a replacement badge will be furnished. A dose assessment is
required for all lost or damaged badges. The radiation badge from the previous
quarter must be turned in promptly when a new badge is distributed. Please turn in
any old badges that are found to EHRM - 1005 for credit. Also, notify the
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Radiation Safety Officer if you terminate your employment and turn in your
badges.
The radiation badge should be worn properly between the neck and waist area with
the back of the badge facing the body. The radiation badge should only be worn
by the individuals whose name is on the badge because it is a measure of that
individual’s personal exposure. The radiation badge in no way provides protection
from radiation. Its sole purpose is to measure the amount of radiation to which it is
exposed.
Do not experiment with a radiation badge by deliberately exposing it to radiation.
The radiation badge is only for occupational exposure measurement at the
University of Houston. Maliciously exposing any radiation badge is prohibited by
state regulations and will lead to disciplinary actions up to and including
termination.
In addition to radiation badges for external exposures, bioassays may be required
to determine potential internal exposures. Bioassays will be necessary when an
individual handles in open form over any three (3) month period, or at any one
time certain quantities of unsealed Iodine -125 (125I) or Iodine -131(131I) as
specified in the regulations. Specifically, a thyroid scan will be required quarterly
for all personnel who work with 1 millicurie or greater amounts of Iodine-125
(125I) at a time. A urinalysis will be required for individuals who work with
shipments of 100 millicuries or greater of Tritium (3H). Bioassays may also be
necessary due to an incident resulting in internal deposition from accidental
inhalation, ingestion, injection, or adsorption of a radioisotope.
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The University of Houston
Pregnant Employee’s Guide to Radiation
Environmental Health &Risk Management
4211 Elgin, Room 183
Houston, TX 77204-1005
General Services Bldg., Area 17
Telephone: (713) 743-5858
Fax: (713) 743-8035
To assist the occupationally-exposed pregnant employee to
assess the potential risks to the unborn child, this document
will explain in general the risks associated with radiation
exposure during pregnancy. The UH guidelines regarding
fetal dose incorporates safety information and radiation
dose regulations to ensure safe radiation exposure limits to
the embryo/fetus of occupationally exposed employees.
Adverse health effects from exposure to ionizing radiation
are thought to have a direct relationship to the dose of
radiation received. Experts assume that, any level of
ionizing radiation has a potential for causing some
biological damage because scientific research has not
proven otherwise. In effect, the research postulates that
there is a theoretical, non-zero risk at low doses and low
dose rates, i.e. no known amount of ionizing radiation
below which adverse health effects may not occur.
The Nuclear Regulatory Commission (NRC)1 has adopted a
risk value for an occupational dose of 1 rem (0.01 Sv) Total
Effective Dose Equivalent (TEDE) of 4 in 10,000 of
developing a fatal cancer, or approximately 1 chance in
2,500 of fatal cancer per rem of TEDE received. The
uncertainty associated with this risk estimate does not rule
out the possibility of higher risk, or the possibility that the
risk may even be zero at low occupational doses and dose
rates. This is based on the assumptions that the dose is
delivered incrementally within the year (the risk is
somewhat higher for a single exposure of this magnitude).
Therefore, for radiation protection purposes, it is prudent to
assume that even small amounts of radiation present some
level of risk.
Prenatal Radiation Exposure
Studies of pre-conception risks show that there is a small
amount of risk associated with radiation exposure of sperm
or ova before conception. The probability is estimated as
1.5 per 1,000,000 for the 0.1 rem (1 mSv) maximum
permissible dose. The current incidence of genetic
abnormalities in the general population is greater than
42,000 per 1,000,000 live births. Thus the incremental risk
of 1.5 per million is almost negligible for this category of
exposure.
Effects on the embryo/fetus
The risk of radiation to a developing fetus is complex and
not fully understood. Different effects take place at
different stages of fetal development. The embryo/fetus is
more sensitive to radiation damage than adults. During the
first trimester, the embryo/fetus is especially susceptible to
radiation exposure. Therefore, if you are considering a
declaration of pregnancy, it is best to declare as soon as
possible for full embryo/fetus monitoring.
Radiation Dose Limits
The sensitivity to radiation of the unborn child is taken into
account in the recommendations for radiation protection
purposes. A dose equivalent to the embryo/fetus from
occupational exposures of 500 mrem has been
recommended by the NRC and the Texas Department of
State Health Services (DSHS). This limit, based on a
review of available scientific literature provides an
adequate margin of protection and reflects the intention to
limit the total lifetime risk of leukemia and other cancers
associated with radiation exposure during pregnancy.
A pregnant worker can decide to keep her pregnancy
confidential; or officially declare her pregnancy to the
Radiation Safety Officer (RSO). A pregnant worker must
voluntarily declare her pregnancy to take advantage of the
lower exposure limits and dose monitoring provisions
specified in the regulations. These requirements are
implemented to prevent discrimination on the job. A
declared pregnancy is one in which the pregnant
employer voluntarily informs her employer, in writing, of
her pregnancy and gives the estimated date of
conception2.
Instructions for Pregnancy Declaration
To formally declare her pregnancy at the University of
Houston, the pregnant employee must voluntarily inform
the RSO in writing of her pregnancy, stating the estimated
date of conception using the designated form on the other
side of the brochure. The Declaration of Pregnancy form is
also found in the Radiation Safety Manual3. Complete the
required information, sign and submit the form to the RSO
in Environmental Health and Risk Management (EHRM)
MC-1005. The declaration will remain in effect until
completion of pregnancy up to one year after submission
unless the employee withdraws the declaration. The
employee may decide to undeclare the declaration of
pregnancy at any time without explanation, but it must also
be submitted to the RSO in writing.
Pregnancy is Declared
In general, occupational exposures are low for radiation
workers at the UH, but it is a regulatory requirement to
limit the radiation dose from occupational exposure to 500
mrem during the duration of pregnancy and not to exceed
50 mrem per month. The RSO must also follow other
regulatory requirements related to the declaration. You will
be given a monthly radiation badge to be worn around the
waist area. This is in addition to any badge the employee
may have been assigned.
Any options such as modification of radiation work will be
discussed between the employee, the RSO and the
departmental supervisor. You may also ask your supervisor
for a job that does not involve any exposure to occupational
radiation dose, but UH is not obligated to provide you with
a job involving no radiation exposure. The final decision on
the level of acceptable risk remains solely with the
employee.
Pregnancy is Undeclared
To withdraw the pregnancy declaration, submit the request
in writing to the RSO by signing the bottom portion of the
Pregnancy Declaration Form. Once withdrawn, the lower
dose limit will no longer apply and the monthly fetal dose
monitor will be discontinued. Again, no explanation is
required.
Further information to pregnant employees in making
decisions regarding radiation exposure during pregnancy is
provided in the references below which are included in the
radiation safety training courses handout materials.
1
US NRC Regulatory Guide 8.29: Instruction Concerning Risks
from Occupational Radiation Exposure, 1996.
2
US NRC Regulatory Guide 8.13: Instruction Concerning
Prenatal Radiation Exposure 1999.
3
UH Radiation Safety Manual
www.uh.edu/plantops/ehrm/radiationsafety
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Radiation Safety Manual
Guidelines f or Radiation Laboratories Changes and Services Changes and services in a radiation laboratory should be done properly and in a
safe manner. These include laboratory moves, modifications, maintenance and
housekeeping. Special considerations must be given for equipment moves,
transfers, or disposal.
All unwanted radioisotopes, samples, and radioactive waste should be disposed
prior to a move. All obsolete x-ray machines, lasers, and radiation labeled
equipment should also be disposed. Old labs must be decontaminated and a final
survey and wipe test taken to show compliance. The Principal Investigator must
submit an amendment form to delete an old lab from their sublicense or
subregistration.
Principal Investigators may move their own radioactive material, but sturdy
containers must be used. These containers must be able to contain any liquid from
breakage and shielding must be considered. Care must be taken to assure that
contamination is minimized. The Labor Crew will not move and Property
Management will not accept or dispose of any radiation or radioactive labeled
equipment without the prior authorization of Radiation Safety.
Radiation Safety will verify that the labs are completely cleared of radioactive
material, radioactive waste, and radiation labeled equipment prior to close out.
Radiation Safety will perform a final survey and wipe test and then remove all
signage. New faculty may not take over and move into the old labs until they
are released by Radiation Safety.
Principal Investigators leaving the University must read and follow the Checkout
Procedures found in the Safety Manual located via the Internet at
http://uh.edu/plantops/ehrm/ehrm_forms.html. There is a checklist to assist the
Principal Investigator and a formal written notice to be completed and sent in to
Radiation Safety at least 30 days prior to departing at EHRM-1005.
It is the responsibility of the Principal Investigator to assure that the area in the lab
to be modified or receive maintenance is free of radioactive contamination and
presents a minimal radiation exposure hazard. All work with radioactive materials
x-ray machines, and lasers should cease while the modification or maintenance is
being carried out. Direct support and supervision by lab personnel should be
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provided as needed for Plant Operations personnel or external contractors.
Custodial personnel or routine maintenance workers must also be protected and
given specific instructions on how and when such work can be performed.
There are also equipment considerations. X-ray machines and lasers cannot be
moved, transferred, disposed or scrapped for parts without prior notification and
approval of Radiation Safety. The Principal Investigator must submit an
amendment form to delete listed equipment from their subregistration. Principal
Investigators may not transfer x-ray machines and lasers to another researcher
unless that individual is authorized. X-ray machines and lasers must be rendered
nonfunctional prior to disposal. X-ray tubes must be removed and power cords
cut. Verification by Radiation Safety may be required. X-ray machines and lasers
must be inspected and approved by Radiation Safety prior to startup after each
move. Appropriate safety devices must be in place and functional as required.
Radioactive material labeled equipment may include refrigerators, freezers,
centrifuges, incubators, fume hoods, etc. Radioactive material labeled equipment
must not be moved into laboratories not authorized for radioactive material use.
Surveys and wipe tests must be performed and documented. Contaminated
equipment must be decontaminated to acceptable levels. Radiation Safety may
double check the equipment for contamination. The labels must be removed if the
equipment is disposed.
Radiation Safety is not responsible for transferring or disposing of equipment.
Radiation Safety is responsible for assisting with procedures and associated
paperwork and assuring that good health physics practices are followed.
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Respiratory Protection The use of respiratory protection is necessary when it is not practicable to limit the
concentration of radioactive material in air to acceptable levels using engineering
controls. Administrative processes may also be implemented, but are not a
preferred control measure.
In general, powdery radioactive material and other radioactive material which
generate aerosols should be handled in a glove box or fume hood, negating any
need for a respirator. The use of a gloved box provides full containment and a
properly operating fume hood usually provides adequate protection for most
ongoing procedures. However, some experiments conducted outside of a gloved
box or fume hood, or on an open bench, may require the use of respirators to limit
intakes of radioactive material. While such protocols are rare at the University of
Houston, no such activity should be conducted without the prior approval of the
Radiation Safety Officer. In all cases, proper personal protective equipment should
be used.
The EHRM Department has developed general respiratory protection procedures to
guide all university employees who may require respiratory protection; this is
found in the EHRM Safety Manual at http://www.uh.edu/plantops/ehrm/ehrm_
manuals.html . The procedures in this document apply only to UH employees.
Contractors, subcontractors, vendors and any other parties are expected to follow
OSHA respiratory protection standards. The procedures provide an understanding
of respiratory protection and stipulate the training and medical requirements for all
employees seeking respiratory protection.
Upon identification of the potential respiratory hazards by intended users in
conjunction with their supervisors, notify the RSO at 713-743-5858. All intended
users of respirators must
•
•
•
Complete a respiratory protection training class offered by EHRM.
Undergo medical evaluation to be approved by licensed physician, and
Be fit-tested by EHRM for their assigned air purifying respirator.
EHRM will recommend a pre-approved occupational health clinic. The PI is also
encouraged to consult with EHRM in the selection and purchase of respirators for
his/her assigned personnel.
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The PI will develop in advance, and obtain the approval of the RSO, a Respirator
Protection Plan for all users to include at least the following:
• A plan for intermittent testing of respirators for operability (user seal check
for face sealing devices and functional check for others) immediately prior
to each use,
• Supervision and retraining of respirator users
• Respirator selection (must be NIOSH approved).
• Inventory and control
• Storage, issuance, maintenance, repair, testing, and quality assurance of
respiratory protection equipment. The EHRM respiratory protection training
class provides respirator care instructions.
• A plan for re-determination of individual’s medical fitness every 12 months
after initial determination or at a frequency determined by physician.
• Limitations on periods of respirator use and relief from respirator use.
The Radiation Safety Officer may recommend air sampling, surveys and bioassays
as appropriate.
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Radioactive Material Sublicense Application and Amendment Guidelines All radioactive material use at the University of Houston must be approved by the
Radiation Safety Officer and authorized by the Radiation Safety Committee.
New Principal Investigators (PIs) must fill out an Application for Radioactive
Material Sublicense and send it to EHRM-1005, for review by the Radiation Safety
Officer (RSO). Application forms can be found in the Radiation Safety Manual
located at http://www.uh.edu/plantops/ehrm/ehrm_forms.html .This sublicense
application must include all radioisotopes, radioactive material users, locations and
procedures. Anyone not listed on the sublicense must not be allowed to work with
radioactive material for any reason.
The use of radioactive material often requires specialized safeguards. Investigative
procedures vary widely as do applicable safety techniques. The information
provided on the application will enable the RSO to formulate necessary safety
measures and assist the PI in implementing these measures. It is important that all
pertinent information is included and the application totally completed. Radiation
Safety Personnel will perform a compliance inspection prior to allowing
radioactive material use.
New PIs also planning to work with radioactive material in animals must complete
an Application for Use of Radioactive Material in Animals and submit it with the
sublicense application. There are additional Radiation Safety Procedures for the
Use of Radioactive Material in Animals. Details concerning the actual use of
animals must be worked out with Animal Care Operations and approved by the
Institutional Animal Care and Use Committee (IACUC).
Authorized PIs planning to make a change to their sublicense must fill out a
Radioactive Material Sublicense Amendment Form and send it to RSO for review.
This includes additions and/or deletions to the sublicense.
The RSO will submit all applications to the Radiation Safety Committee for
approval. The RSO may give interim approval to Principal Investigators until the
next Radiation Safety Committee meeting. When the RSO finds reason to give an
interim authorization to a new PI, prior to Radiation Safety Committee approval,
the authorization will be limited to 90 days to allow sufficient time for a committee
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meeting (with quorum) to discuss and then approve, deny, or issue conditionally a
new sublicense to the PI. A temporary sublicense permit with a 90 day expiration
date will be issued with the RSO’s signature until the Radiation Safety Committee
approval is valid. A new permit will then be issued which includes the Chair’s
signature.
Approved PIs will receive an Authorization Permit to work with radioactive
material, which is proof of radiation authorization at the University of Houston and
may be submitted with Grant Proposals. Once authorized, the PI will remain
authorized until either sublicense termination by the PI or the sublicense is revoked
by the Radiation Safety Committee for noncompliance.
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Radioactive Material Receipt, Package Check­In, Inventory Number, Record of Use, Transfer, and Lab Storage Procedures Package Receipt All radioactive material packages must be delivered to the Environmental Health
and Risk Management Department (EHRM). The EHRM Department is located in
the General Services Building, Room 183. The EHRM office is open Mondays
through Friday for business from 8:00 am to 5:00 pm. No radioactive material
packages will be accepted outside normal business hours and on weekends or
holidays.
Package Check­In All radioactive material shipments are checked in, inspected, and delivered as soon
as possible to the labs by radiation safety personnel. This service is provided to
ensure package contents are intact, accurate and do not pose exposure or
contamination hazards to lab personnel. Unless lab personnel are specifically
authorized to work with them, high exposure rate packages may be held for partial
decay and then delivered. Packages with unacceptable levels of contamination will
need further assessment.
Inventory Number Each radioisotope is assigned a specific inventory number. This is recorded on the
vial, any vial container, and the Radioisotope Package Survey and Wipe Test &
Radioisotope Tracking Form. A Radioisotope Logbook is maintained as part of
the Radiation Safety Records and a six months inventory of all radioisotopes is
routinely performed. A physical review of all inventoried radioactive material
stock vials will be performed during the comprehensive lab audits.
Record of Use The recorded use of each radioisotope is maintained on the Radioisotope Package
Survey and Wipe Test & Radioisotope Tracking Form. This form must be kept up
to date and filled out completely. The form must be returned to EHRM-1005 upon
completion of the original stock vial. The form must indicate that the radioisotope
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is decayed to background levels, used up with zero activity or placed for
radioactive waste disposal (Note: The Radioactive Waste Disposal Form is a
separate form). Upon receipt of the completed form, the radioisotope will be
deleted from the radioactive material inventory. Failure to return the forms in a
timely manner may cause the PI to exceed maximum possession limits and prevent
or delay approval of radioisotope orders.
Transfer of Radioactive Material All transfers of radioactive material between PIs within the university must be
documented and approved by Radiation Safety Officer. The Transfer of
Radioisotope Form is to be used for all transfers. A new Radioisotope Package
Survey and Wipe Test & Radioisotope Tracking Form will be issued for the
transferred radioisotope.
PIs leaving the university and transferring their radioactive material to another
institution must properly ship them in consultation with the Radiation Safety
Officer and provide a 30-day prior notification.
Lab Receipt and Storage Radioactive material packages will be delivered to approved laboratories, and
authorized users only. Upon receipt of these materials, all radioactive material must
be kept in a secure area to prevent unauthorized removal. Radioisotopes must also
be stored behind sufficient shielding to reduce radiation exposures to less than 2
mR/Hr. Radiation Safety personnel will inspect all radioactive material labs to
ensure that appropriate safety measures are in place and proper safety procedures
are being followed prior to allowing work with radioisotopes.
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Radioactive Material Procurement Procedures Radioactive Material can only be ordered on a Purchase Requisition through the
Purchasing Department per the University of Houston Manual of Policies and
Procedures (MAPP) 04.01.01. All Purchase Requisitions for radioactive material
must be approved in advance by Radiation Safety personnel. It is preferred that
chemical compounds containing uranium or thorium be purchased as radioactive
material, because these compounds are usually subject to radioactive waste
disposal requirements. Free shipments, samples and/or replacements of radioactive
material must also be approved. Radiation Safety personnel will verify that
Principal Investigators are authorized for the requested radioisotopes and will not
exceed maximum possession limits.
Purchase Requisitions may be brought to Environmental Health and Risk
Management located in the General Services Building, Room 183; faxed to 713743-8035; or mailed to EHRM-1005. Please call 713-743-5858 before bringing
orders over for approval to ensure Radiation Safety personnel will be available to
sign-off on your order. Every order should be accompanied by an Addendum B per
the Purchasing Department. Radiation Safety personnel will stamp and sign each
order. Normally, orders will be promptly approved unless there are some issues to
be addressed. Purchasing Department will reject orders without Radiation Safety
personnel’s approval. Also, Purchase Requisitions lacking the necessary
information, improperly filled out, or outside the Principal Investigator’s
authorization will be delayed.
Problems with orders after Radiation Safety approval should be addressed directly
with Purchasing department or the vendors. Radiation Safety personnel are
generally responsible for pre-approvals, package surveys upon receipt, and
deliveries to laboratories.
Purchase Order information must include:
32
‰ Radioisotope, e.g.
P, 14C, etc. (Only one radioisotope allowed per Purchase
Requisition)
‰ Maximum activity per vial, e.g. 500 microcuries, 500 µCi, 0.5 mCi, etc.
(not specific activity , e.g. Ci/mmole)
‰ Compound(s), e.g. DCTP, Thymidine, etc.
‰ Total number of vials
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‰
‰
Name of the Principal Investigator authorized for the order.
Deliver shipment to:
Environmental Health and Risk Management
4211 Elgin St., Room 183
Houston, TX. 77204-1005
Blanket Orders are only approved for the radioisotope, number of vials, and total
activity indicated. Radiation Safety personnel are not responsible for maintaining
Blanket Orders, but only the regulatory requirements associated with them. In
addition, vendors do not maintain Blanket Orders. Therefore, Principal
Investigators are responsible for keeping up with all aspects of their Blanket
Orders.
It is imperative to provide a valid Purchase Order number to Vendors with each
order. Principal Investigators with multiple Blanket Orders must not mix up
Purchase Order numbers. Additional orders against a completed Blanket Order are
not allowed. A change order to increase an existing Blanket Order may be
completed with the Purchasing Department after pre-approval by Radiation Safety
personnel. Blanket Orders may not be used past their expiration date; therefore,
new Blanket Orders are required each fiscal year.
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Radioactive Materials Laboratory Setup Guidelines General Radioactive material shall be used only in those locations which have been
approved on your sublicense by the Radiation Safety Committee. A Principal
Investigator wanting to add a radioactive material use location must submit a
completed sublicense amendment to the Radiation Safety Officer which provides
details of the area and the proposed uses and receive approval by the Radiation
Safety Committee. The setup of the radioactive material work area will be
reviewed by the Radiation Safety personnel.
Signage All radioactive material labs must be properly posted with “Caution Radioactive
Material, No Smoking, Eating, or Drinking in The Laboratory” signs, and other
such signage at each entrance. This signage will be provided and posted by
Radiation Safety personnel. They shall be visible at all times. Lab personnel should
contact radiation safety personnel for a replacement sign if the one provided has
been removed.
Postings Radioactive material labs must be properly posted with copies of the “Notice to
Employees” from the Texas Regulations for Control of Radiation, the Document
Location Notification, and the Radiation Emergency Procedures. These will be
provided and posted by Radiation Safety personnel. They shall be visible at all
times. Lab personnel should contact radiation safety personnel for replacement
postings if the ones provided have been removed.
Restricted Access Access to all radioactive material labs should be restricted to authorized personnel
only. Housekeeping or maintenance personnel may be allowed into these areas to
perform their functions as previously arranged or at other times under the direct
supervision of laboratory personnel who can assure their safety. Personnel
monitoring badges will not be required for housekeeping or maintenance
personnel.
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Doors to all radioactive material labs must remain shut at all times. These doors
must be locked if no authorized user is present. Radioactive material must remain
secure at all times from unauthorized removal.
Survey and Analytical Instrumentation A survey meter which is appropriate to the type and level of ionizing radiation used
must be obtained and made available for users of high energy beta and/or gamma
emitting radioisotopes. Labs using low energy beta emitters like 3H, 14C and 35S
only are not required to purchase a survey meter. Liquid Scintillation or Gamma
Counters must be available for Principal Investigators to perform their required
wipe tests.
Shielding Shielding materials shall be made available appropriate to the types and levels of
radiation in all laboratories. High energy beta emitters should be shielded with at
least 3/8 inches of plexiglass to minimize the creation of bremsstrahlung radiation.
Work and storage areas must be shielded such that the dose rate at one foot does
not exceed 2 mR/hr. In general, exposures should always be kept “As Low As
Reasonably Achievable” (ALARA). The ALARA program is set to keep
occupational exposures under 1/10 of the allowable maximum permissible
exposure limits.
Handling Equipment Containers with more than 100 microcuries of gamma or high energy beta activity
should not be handheld for more than a few seconds. Tongs, forceps, or some
other remote handling tool should be used. Liquid or loose radioactive material
should be contained in a secondary unbreakable corrosive resistant container.
Fume Hoods Experiments that generate aerosols or use volatile compounds of radionuclides
must be performed in an approved fume hood. All iodinations must be performed
in an approved fume hood without exception. Additionally, experiments with
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radionuclides should be performed in an area under negative air pressure. Refer to
the fume hood procedures in the EHRM Safety Manual for more information.
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Radioactive Material Laboratory Safety Guidelines Basic laboratory safety guidelines are necessary to ensure personnel safety and
prevent radioactive contamination, or spills. Consistent and active participation by
all lab staff is essential.
The following set of guidelines is not exhaustive.
• Non-essential personnel should not be allowed in the laboratory while
radioactive procedures are in progress.
• A portion of the laboratory should be set aside only for radioactive
procedures. Locate these work areas away from heavy traffic and
doorways.
• Work with radioactive material should be done rapidly but carefully.
• Every container of radioactive material should be labeled for identification
with the radiation warning symbol and pertinent information such as the
radionuclide content, date and activity.
• Exercise deliberate care in handling radioactive material and transport them
in doubly contained and shielded containers when necessary to protect
against external radiation exposure and spills.
• Wear laboratory coats and other protective clothing at all times in areas
where radioactive material is used.
• Wear disposable gloves at all times while handling radioactive material.
• Do not eat, drink, smoke, apply lip balm, or apply cosmetics in any area
where radioactive material is stored or used.
• Do not store food, drinks, or personal effects with radioactive material.
• Dispose of radioactive waste only in specially labeled and properly shielded
receptacles.
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• Never pipette by mouth.
• Absorbent paper shall be used to cover workbenches, trays, and other
surfaces where radioactive material is handled.
• Monitor hands and clothing for contamination after each procedure or before
leaving the area. This is done using a survey meter.
• Survey all areas where radioactive materials are used in uncontained form
after each procedure and/or at the end of the day. Decontaminate
immediately if necessary.
• Radioactive material in liquid form should be stored and transported in
double containers.
• Work should be planned ahead, and whenever possible, a practice run should
be performed to test the procedure.
• The laboratory should be kept clean and orderly at all times.
• Survey meters should be checked routinely with a source of radiation to see
if they are responding properly. A battery check should be performed
before each use.
• Radiation Badges shall be worn at all times while in areas where radioactive
material is stored or used if assigned. Ring badges shall be worn at all
times when handling radioactive material if assigned.
• All radioactive material shall be secured at all times to prevent unauthorized
access and the lab must be locked when unattended.
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Radioactive Material Laboratory Survey and W ipe Test Procedures Radiation exposure and radioactive contamination may be a significant source of
radiation dose in the laboratory. In order to know if the working surfaces in your
laboratory are free of radioactive contamination, a contamination check should be
performed after each experiment. This check can be with a survey meter and/or a
wipe test. These checks are necessary to keep radiation exposures As Low As
Reasonably Achievable and do not replace the mandatory laboratory surveys and
wipe tests.
Frequency Radioactive Material Principal Investigators with active use of radioisotopes are
required to perform monthly lab surveys and wipe tests on all listed labs in which
there is use or storage, e.g. counting rooms, cold rooms, shared rooms, and other
such rooms. However, the Radiation Safety Officer (RSO) may recommend a
different wipe test frequency depending on the radionuclides and amounts used.
Listed labs in which there is no use or storage will require documentation as
inactive, if surveys and wipe tests are not performed. Radiation Safety personnel
also perform lab surveys and wipe tests on a quarterly basis to verify compliance.
Lab surveys and wipe tests are to be performed and due by the 15th of each month,
to the Radiation Safety Officer at EHRM-1005 or faxed to 713-743-8035. Lab
surveys and wipe tests received late will be cited for noncompliance and chronic
violations may jeopardize the sublicense. It is mandatory that all required lab
surveys and wipe tests be completed without exception each month to prevent a
Notice of Violation to the university from the Texas Department of State Health
Services. The Radiation Safety Officer will maintain these records as required for
the state inspection.
Only inactive Radioactive Material Principal Investigators without any radioactive
material stored or used are exempt from these procedures. A Radioactive Material
Principal Investigator may become inactive at any time by notifying the RSO and
properly disposing of all radioisotopes, samples, and waste. Conversely, an
inactive Radioactive Material Principal Investigator may become active by
notifying the RSO.
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Surveys A survey with a portable, thin-window detector, survey meter must be performed
on all labs using radioisotopes other than 3H, 14C and 35S (Low energy beta
emitters). Wipe tests are preceded by an overall survey to determine immediate
external exposure hazards and areas which require greater attention in wipe testing.
Before using any survey meter, check for current calibration and proper
functioning. If the batteries are weak, replace them before performing the survey
because the readings will not be accurate. Check that the meter is properly
responding by holding the probe close to the radiation source provided with the
meter or a source that will give a similar response.
Several probe types are available for portable survey instruments. The most
common types are the end-window, pancake, and side window probes. All probes
are to be positioned so that the window is facing the area to be checked. For the
side window probe, the shield must be opened when surveying for beta emitter
contamination.
Monitoring for contamination is performed by slowly moving the detector over all
surfaces at a distance of approximately 1 centimeter. The survey meter should be
turned on before entering any radiation area starting with the lowest setting. The
audio should always be on since small increases of radiation exposure are easily
detected by listening to the clicks. It is easier to pay attention to the surface being
monitored if the meter does not have to be constantly watched. Care must be taken
not to contaminate the probe by touching the area being checked.
Any area found to have an exposure rate of twice background or greater with the
survey meter is considered contaminated. This area must be immediately
decontaminated and then resurveyed to confirm that the area is below twice
background.
Calibrations of survey meters are performed annually via EHRM. A calibration is
also required after a repair or the replacement of parts (e.g. probe). Radiation
Safety personnel will pick up the meter and provide a loaner meter while yours is
being calibrated. When the meter is returned, it will have a calibration label
affixed to the side or bottom with the date of calibration and serial number for the
instrument. The calibration certificate will also be provided.
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W ipe Tests Cotton swabs or small filter paper discs are used for wipe tests. Either dry or wet
wipe tests are acceptable. To perform a wipe test, first wipe the outer perimeter of
least suspected contamination and then move to the center of highest possible
contaminated last in order to prevent the spread of contamination. For example,
one would wipe the sash and outer area of a fume hood before wiping the inner
shield or surfaces. Personal protective equipment must be worn when performing
wipe tests.
Wipes are taken at strategic locations around the laboratory with typically, 10 to 15
wipes taken in a normal use lab. Any area found to have a wipe test count of 200
dpm per 100 cm2 or greater from a liquid scintillation counter or a gamma counter
is considered contaminated. This area must be immediately decontaminated until
the wipe test shows a count below 200 dpm. Areas to consider for testing include:
-
work benches
fume hoods
sinks and adjacent areas
radioisotope storage areas
refrigerator/freezer surfaces and handles
light switches and door knobs/handles
telephone handsets and key pads
centrifuge handles and controls knobs
incubators
floors beneath work areas and around waste areas
Documentation Lab surveys and wipe tests must be recorded on the Radioactive Material
Laboratory Survey and Wipe Test Form. Please use the Radioactive Material
Laboratory Survey and Wipe Test Form issued by Radiation Safety, with the
diagram of your lab already drawn. The location of each survey and wipe test
must be properly identified on the form. Information on the forms must be
completely filled out or it will be rejected. Remember to make photocopies of the
form for future use.
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Radiation Safety Procedures f or the Use of Radioactive Material in Animals A Radioactive Material Principal Investigator with a Sublicense, planning to use
radioactive material in animals must fill out an Application for Use of Radioactive
Material in Animals, and send it to Radiation Safety at EHRM-1005, for review by
the Radiation Safety Officer. Radiation safety forms can be found in the Radiation
Safety Manual located at http://www.uh.edu/plantops/ehrm/index.html
The use of radioactive material in animals requires additional safeguards in the
handling of affected animals. Investigative procedures involving animal systems
vary widely as do applicable safety techniques. The information provided on the
application will enable Radiation Safety to formulate necessary safety measures
and assist the Principal Investigator in implementing these measures. It is
important that all pertinent information is included and the application fully
completed i.e. experimental protocols must be described in detail.
Details concerning the actual use of animals must be worked out with Animal Care
Operations and the research protocol approved by the Institutional Animal Care
and Use Committee (IACUC). No research activities using animals can be started
without prior approvals.
The Radiation Safety Officer will submit all applications to the Radiation Safety
Committee for approval after review. However, the Radiation Safety Officer may
give interim approval to Principal Investigators for the Radiation Safety
Committee. Approved Principal Investigators will receive an amended
Authorization Permit to work with radioactive material in animals, which is proof
of radiation use authorization at UH and may be submitted with Grant Proposals.
Once authorized, the Principal Investigator will remain so until sublicense
termination by the Principal Investigator or revoked by the Radiation Safety
Committee for noncompliance. The Institutional Animal Care and Use Committee
will be notified and provided with a copy of the approved application.
The PI is responsible for the overall radiation safety of the project, including
radiation exposure monitoring of the animals, cages, and procedures; analytical
determination of radioactivity in urine, feces, and bedding; and labeling of all
cages containing radioactive animals. Tags for this purpose must indicate the
radioisotope, the activity (in µCi or mCi) and the date. Animal Care Operations
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must be notified at least five working days prior to housing radioactive animals in
their facility. Such notification is not necessary for use within the Principal
Investigator’s approved labs.
All animal remains, i.e., viscera, tissue, serum, or other fluids, and the carcass,
containing radioactive material [except tritium (3H), carbon-14 (14C) and Iodine125 (125I) as described below] are to be disposed as follows:
•
Place the remains in a yellow radioactive materials waste bag. Secure the
bags shut with tape and attach an Incineration Tag showing the
radioisotope, the activity (in µCi or mCi) and the date. The bag is to be
placed in the radioactive material labeled freezer located in the Animal
Care Facility as prearranged with Animal Care personnel.
•
Animal remains containing Tritium (3H), Carbon-14 (14C) and Iodine125 (125I), in quantities less than 0.05 microcuries per gram weight, may be
disposed of as non-radioactive waste. Place the remains in a clear waste
bag without a radioactive material label. The bag is to be placed in the
non-labeled freezer in the Animal Care Facility as prearranged with Animal
Care personnel. Nevertheless, the Principal Investigator must continue to
keep an inventory record with the date, activity, and radioisotope (3H, 14C,
or 125I) used in the animal.
The following table will help in determining activity levels in animal remains that
may be disposed of as non-radioactive waste.
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AMOUNT OF H­3, C­14 OR I­125 IN ANIMAL REMAINS THAT MAY BE DISPOSED OF AS NON­RADIOACTIVE WASTE Weight
Activity
Weight
Activity
gm
lb .
µCi
kg
lb .
µCi
100
0.22
5
2.5
5.5
125
200
0.44
10
3.0
6.6
150
300
0.66
15
3.5
7.7
175
400
0.88
20
4.0
8.8
200
500
1.1
25
4.5
9.9
225
600
1.32
30
5.0
11
250
700
1.54
35
7.5
16.5
375
800
1.76
40
10
22
500
900
1.98
45
20
44
1.0 mCi
1 kg
2.2
50
30
66
1.5 mCi
1.5 kg
3.3
75
40
88
2.0 mCi
2.0 kg
4.4
100
50
110
2.5 mCi
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Radioactive Waste Disposal Procedures Radioactive waste requires the same safety and security measures given to all
radioactive material. The PI is responsible for the safe, secure, and proper storage
of radioactive waste generated until removed by EHRM department. The
University’s Radiation Safety Manual establishes guidelines and ensures
compliance with the required procedures for collection, packaging, labeling,
transport and disposal of radioactive waste generated within the University of
Houston. Your assistance and cooperation with all waste handling procedures in
compliance with sublicense requirements is essential.
Radiation Safety personnel are responsible for the pickup and disposal of all
radioactive waste from the labs. Radiation Safety personnel must directly handle,
repackage, and physically dispose of the radioactive waste. Radiation Safety will
consequently cite radioactive waste violations pertaining to the radioactive waste
areas in the labs and the radioactive waste picked up from the labs. Serious
violations such as sharps found in solid waste bags pose an immediate danger.
Poor radioactive waste disposal practices also lead to a higher threat of radioactive
material contamination and spills. Noncompliance items are expected to be
corrected immediately and then procedures put in place to prevent recurrence.
PIs are responsible for implementing effective radioactive waste management
procedures in the labs. They must provide adequate radioactive material labeled
receptacles for each radioisotope and type of radioactive waste generated. The
disposal of all radioactive waste must be recorded on the Radioactive Waste
Disposal Form. The Radioactive Waste Disposal Form is found in the Radiation
Safety Manual located at http://www.uh.edu/plantops/ehrm .
Radioactive waste should not be stockpiled in the lab. A radioactive waste area
should be located away from heavy traffic or high use areas. Adequate space for
shielding should be considered. High energy beta and gamma emitters must be
stored behind the appropriate shielding material to minimize the external exposure
to lab personnel. Plan to contain liquid waste in the event of a spill or failure of the
plastic carboy. Containment can be easily achieved by placing the carboy or liquid
waste container in a secondary container or by using plastic backed absorbent
paper beneath them.
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Do not, under any circumstances, place radioactive waste where it might be picked
up by housekeeping personnel and be disposed of as ordinary waste in the
dumpsters. Accidental and improper radioactive waste disposal must be reported
immediately to the Radiation Safety Officer.
Before requesting a radioactive waste pickup, please make sure the containers are
properly sealed and Radioactive Waste Disposal Forms are completely filled out
and attached. Full waste containers that require shielding should not be left outside
of shields while awaiting pickup. All requests for radioactive waste pickups in the
labs or other special areas will be completed online using the UH Hazardous Waste
form link. The interactive form streamlines the documentation of waste
information and provides a printable record for reference. Be prepared to provide
specific information such as Principal Investigator, location, waste type, number of
containers, etc. In addition, indicate if replacement radioactive material bags,
carboys or sharps containers are needed. A reference number will be issued with
every request. The waste will continue to be picked up as scheduled unless there is
inclement weather.
Waste Segregation and Minimization In a continuing effort to minimize the volume of radioactive waste disposed in
licensed land disposal facilities, the EHRM department has implemented various
waste minimization programs. For these programs to succeed, it is necessary that
all PIs and lab personnel follow proper radioactive waste procedures as much as
possible.
Radioactive waste must be segregated by radioisotope and physical form. The only
general exceptions are the radioisotopes Tritium (3H) and Carbon-14 (14C) which
can be put together. Any other requested exception must be approved by the RSO.
The 10 basic physical forms are: solids, glass, sharps, liquids, liquid scintillation
vials (LSV), biological, animal remains, source vials, lead pigs and sealed sources.
Solid
Solid radioactive waste is comprised mostly of solid disposable items that have
been contaminated with radioactive material including absorbent work surface
coverings, gloves, tubing, etc. This waste is disposed in yellow radioactive
material bags supplied by EHRM. Do not use any other type of plastic bag to
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collect the solid radioactive waste. The yellow radioactive material bags must be
placed in closed waste receptacles that must remain closed at all times. Deface or
remove all radioactive labels before placing waste into the bags. Do not place
anything in the bags in such a way that they may tear it. Inspect the plastic waste
bag for leaks prior to removal from the lab. Use a second yellow bag to contain the
waste if necessary. Do not mix liquid scintillation vials, lead pigs, and stock vials
with the solid waste, especially sharps. Plastic source vial containers, but not the
lead impregnated type, may be disposed in the solid waste after being defaced of
all radioactive labels. Every bag must be securely sealed and have a completed
Radioactive Waste Disposal Form attached prior to pickup.
Glass
Contaminated glassware and other unbroken glass should be packaged separately
from other solid radioactive waste. A strong cardboard box is adequate for
disposal use. Every box must be securely sealed and have a completed Radioactive
Waste Disposal Form attached prior to pickup.
Sharps
Sharps are defined as anything that could tear the yellow radioactive material bag
including needles, broken glass, glass pipettes, razor blades, capillary tubes, etc.
This waste type is disposed in clear, puncture resistant plastic tubes supplied by
EHRM. These tubes are only for the disposal of radioactive contaminated sharps.
Be careful putting sharps into the container and do not overfill. Make sure that all
sharps are dry before placing into container. When full, securely cap tube with
orange/red top. Every tube must have a completed Radioactive Waste Disposal
Form attached prior to pickup.
Liquid
The category of radioactive liquid waste can be further divided into aqueous, acids
and bases, and pump oils. Aqueous liquids are water-based liquids with a pH
between 5.0-9.0, such as saline and buffer solutions or washings from radioactive
contaminated laboratory glassware, weak acids and bases that contain no
biological, pathogenic, or infectious materials. Liquid waste is disposed in 5
gallons plastic containers called carboys, supplied by EHRM. These carboys are
not to be filled more than 4/5th full to prevent spills or overflows. After emptying
lab ware of radioactive liquid, the first three rinses of lab ware must also be placed
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in the radioactive liquid waste container. No radioactive liquid is to be poured
down the sink. Sinks will be checked during routine lab surveys and wipe tests.
Pipettes and other such items must not be placed in the carboys. All biological
material in the carboys must be properly deactivated using 10 percent bleach
solution. Do not mix liquid waste types in the carboys.
Double containment in a tray or pan that will adequately contain the liquid is
recommended as a precaution against leakage or a spill. This will also control
accidental overflow and drips due to pouring. At a minimum, plastic backed
absorbent paper shall be placed under all liquid waste containers. Carboys should
be kept as free of contamination as possible. Glass containers must never be used
for storage of radioactive liquid waste unless plastic incompatible contaminated
acids or bases are used. These bottles must definitely be double contained. Every
carboy must have a completed Radioactive Waste Disposal Form attached prior to
pickup.
Liquid Scintillation Vials
Liquid Scintillation Vials are glass or plastic vials containing organic or aqueous
based liquid scintillation fluid. This waste is disposed in the original cardboard
trays and placed in a yellow radioactive material bag or double bagged in yellow
radioactive material bags. Glass vials not in the original trays must be double
bagged in yellow radioactive material bags and placed in a cardboard box. Check
that all vial tops are closed tightly because all scintillation fluids will dissolve
plastic in time. Every bag or box of vials must be securely sealed and have a
completed Radioactive Waste Disposal Form attached prior to pickup.
Biological
This category covers radioactive waste containing biological, pathogenic, or
infectious material including by-product animal waste, labeled culture media, etc.
This waste is disposed either in yellow radioactive material bags supplied by
EHRM and labeled with biological waste stickers, or in red biological bags labeled
with radioactive material stickers. Liquids must be absorbed into some absorbent
material such as paper towels, sponges, gauze, etc. prior to placing into bags.
Pathogenic and infectious waste must be sterilized by chemical treatment or
autoclaving as appropriate. Autoclaves must be checked for radioactive
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contamination after use. Every bag must be securely sealed and have a completed
Radioactive Waste Disposal Form attached prior to pickup.
Animal Remains
This category covers radioactive animal carcasses and by-product waste including
viscera, serum, blood, excreta, tissue, etc. to be incinerated. Animal remains
containing radioactive material are subject to handling according to the guidelines
stated in the Radiation Safety Procedures for the Use of Radioactive Materials in
Animals. This waste is disposed in yellow radioactive material bags supplied by
EHRM. Every bag must be securely sealed and have a completed Incineration Tag
supplied by EHRM showing the date, radioisotope, total activity, and the Principal
Investigator tied to the bag. Liquids must be absorbed into some absorbent
material such as paper towels, sponges, gauze, etc. prior to placing into bags.
Source Vials
These are the original vials that the radioactive material was shipped in to your lab
and includes full, partially full, and empty vials awaiting disposal. . All source
vials must be disposed by Radiation Safety personnel, even if it has decayed.
Radiation Safety personnel will do a final survey on all source vials prior to
disposal. Source vials must be kept separate from the solid waste and placed in a
small cardboard box for disposal. A Radioactive Waste Disposal Form is not
required, but the Radioactive Package Survey and Wipe Test & Radioisotope
Tracking Form should be sent in at the time of their disposal. Segregation by
radioisotope does not apply to source vials.
Lead Pigs
These are the original lead and/or lead impregnated shielding containers
surrounding the source vials. Lead is a hazardous waste and must be disposed
accordingly. Lead pigs and lead impregnated shielding containers must be kept
separate from the solid waste and placed in a small cardboard box for disposal. A
Radioactive Waste Disposal Form is not required. Segregation by radioisotope
does not apply to lead pigs.
Sealed Sources
Sealed sources include calibration sources, check sources, quenched standard sets,
electron capture gas chromatograph detectors, etc. Check for broken or crushed
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sources and handle these damaged sources with extreme care. Call the Radiation
Safety Officer if contamination is found or suspected. All sources must be
disposed by Radiation Safety personnel, even if decayed. Radiation Safety
personnel will perform a final survey and/or leak test on all sources prior to
disposal as necessary. Sealed sources must be kept separate from the solid waste
and placed in a small cardboard box for disposal. A Radioactive Waste Disposal
Form is not required. Segregation by radioisotope does not apply to sealed
sources.
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Radioactive Material Spill, Accident, and Emergency Response Radioactive material incidents may involve three levels of response due to severity
such as spills, accidents and emergencies. All these events may raise exposure and
contamination concerns with potential increased the dose both internally and
externally to the lab personnel. Each incident must be evaluated before proceeding
and approached properly to prevent additional hazards and personnel exposure.
In case of a radioactive incident, proceed as follows:
• Attend to people first
• If possible, contain spill and/or secure radioactive material
• Notify the Radiation Safety Officer
• Decontaminate and properly dispose of waste
Radioactive Material Spill A radioactive material spill may be in the form of liquid, powder, mist, fume,
organic vapor, or gas. The spill may pose cross-contamination concerns to the lab
and adjacent areas as well as personnel.
Two types of spill are possible in a lab situation depending on quantity and
activity.
• Small – Small amount of activity and/or small volume. The cleanup of small
RAM spills is a routine responsibility for RAM users. Radiation Safety
personnel will provide assistance with small spills if requested.
• Large – Large amount of activity or large volume, or a combination.
Radiation Safety personnel must be contacted ASAP for large spills
involving millicurie amounts of activity, high exposures at the surface
(> 100 mR/hr), large volume of fluid (> 1 pint), and/or large surface area
contamination, e.g. entire bench top or lab floor area. Radiation Safety
personnel will take charge of all large spills and verify decontamination to
appropriate levels.
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General procedures:
• Notify all personnel in the room of the spill.
• If personnel are contaminated, personnel decontamination should proceed
immediately using proper techniques as described below.
• Confine the spill as soon as possible.
• Notify the Radiation Safety Officer immediately of significant personnel
contamination and/or large spills.
• Decontaminate the area as described below using personnel protective
equipment and proper techniques.
• Perform surveys and wipe tests to verify that the area has been adequately
decontaminated.
• Dispose of all the spill clean-up material as radioactive waste. These include
any contaminated broom, mops, dust pan, etc.
If you need assistance with a spill after normal working hours, please call the UH
Police Department’s emergency number at 713-743-3333 and the RSO will be
notified.
Every radioactive material lab should have a radioactive material spill kit designed
to handle a small spill. A spill kit should at least contain the following:
Basic Spill kit items
Quantity
Radioactive Decontamination reagent
Plastic Backed Underpads
Radioactive Waste Bag 24x36
Latex Gloves
Cotton Swabs
Shoe Covers
Ziploc Bag 12x15
Ziploc Bag 4x6
1 can
2
1
5 pair
1 bag (100)
2 pair
1
1
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Decontamination Decontamination is the removal of unwanted presence radioactive material.
Contamination can be on an area, on the personnel, and in some cases, involves
injury to personnel. Major personnel injuries take priority over decontamination
which can be performed at a later time.
Each lab should provide appropriate personal protective equipment, e.g. lab coats
and protective eyewear as necessary. Radiation badges should be worn if assigned.
Survey meters are available in most radioactive material labs and can be requested
from EHRM
Personnel Decontamination:
Contaminated clothing, including shoes, should be removed before the individual
leaves the area. This clothing shall be labeled and held in storage until decayed,
decontaminated, or disposed of as radioactive waste.
For decontamination of the skin, use lukewarm water, to avoid reddening the skin
and prevent absorption. Also, use light pressure with heavy lather. Wash for 2
minutes, 3 times. Use care not to scratch or erode the skin. Care must be taken to
prevent internal deposition. Thorough washing, preferably showers, should be
accomplished immediately where major personnel contamination has occurred.
Monitor personnel after washing. Repeat the personnel decontamination procedure
above if necessary.
Personnel Injury:
Call the UH Police at extension 911 if a physician is needed or for life threatening
situation. Minor cuts should be allowed to bleed, thereby reducing absorption.
First aid of major cuts or abrasions, lacerations, etc. should be considered before
decontamination. Proceed with personnel decontamination if possible.
All radiation accidents (wound, overexposure, ingestion, and inhalation) must be
reported to the Radiation Safety Officer as soon as possible.
No one involved in a radiation injury will be permitted to return to work without
the approval of the Radiation Safety Officer.
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Area Decontamination
All persons not involved and not contaminated should leave the area.
Put on lab coat, protective eyewear, gloves and shoe covers before entering the
contaminated area.
Prevent liquids from spreading by placing any absorbing material over it.
Monitor the spill, equipment, and people involved to determine the radiation
exposure levels.
Wash the area with a minimum of soapy water or a standard radioactive
decontaminating agent. Any broken glass or sharps should be swept up using a
broom and dust pan to prevent accidental cuts. Using paper towels, start at the
furthest end or the place of least contamination and move inwards toward the
highest point of contamination.
Using a filter paper or cotton swab, wipe the area. Count the wipe using a
scintillation or gamma counter as appropriate. If the count is greater than 200 dpm,
repeat area decontamination until the count is below this level of contamination.
Dispose of all radioactive waste properly according to the radioactive waste
procedures.
Accident Accident exceeds the single lab ability to decontaminate a spill area and requires
the involvement of Radiation Safety personnel. Accident may involve a release of
radioactive material into the air, water or outside the lab. Radiation Safety Officer
may isolate the room, floor, or the building.
Notify all personnel to leave the area immediately.
Hold your breath and vacate the room.
Notify the Radiation Safety Officer at once. Radiation Safety Personnel will
respond to all accidents and apply applicable control measures to minimize the
spread of contamination and secure the area.
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Keep all access doors locked.
Do not re-enter the room until approval of the Radiation Safety Officer is obtained.
If the accident occurs after hours, please treat it as an emergency and notify the UH
Police department at 713-743-3333.
Emergency Emergencies will be dealt with according to their nature that may include fire, spill,
accident, injury, or a combination. The following is the basics for the handling of
all emergencies:
Notify all personnel in the area.
Contain or secure the radioactive material if possible.
Take care of injuries and remove injured personnel from the area when possible.
Notify the Radiation Safety Officer as soon as possible.
Obtain permission from the Radiation Safety Officer to continue with or return to
work.
Apply decontamination procedures when possible.
Some incidents require mandatory reporting. The Radiation Safety Officer will
notify the appropriate agencies of any incidents required to be reported.
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X­ray Machines and Other Ionizing Radiation Producing Devices Subregistration Application and Amendment Guidelines All x-ray machines and other ionizing radiation producing devices at the
University of Houston must be approved by the Radiation Safety Officer and
authorized by the Radiation Safety Committee.
All x-ray machines and other ionizing radiation producing devices are required to
be registered with the Texas Department of State Health Services under the
University of Houston’s X-ray Registration.
New Principal Investigators (PIs) must fill out an Application for X-ray Machine
Subregistration and send it to EHRM-1005, for review by the Radiation Safety
Officer (RSO). Application forms can be found in the Radiation Safety Manual
located at http://www.uh.edu/plantops/ehrm. This subregistration application must
include all x-ray machines, x-ray users, and equipment locations and procedures.
Anyone not listed on the subregistration permit must not be allowed to work with
x-ray machines for any reason. The x-ray machines must not be used until final
approval is given by the RSO.
The use of x-ray machines often requires specialized safeguards. Investigative
procedures vary widely as do applicable safety techniques. The information
provided on the application will enable Radiation Safety to formulate necessary
safety measures and assist the Principal Investigator in implementing these
measures. It is important that all pertinent information is included and the
application totally completed. Radiation Safety Personnel will perform a
compliance inspection prior to allowing x-ray machine use.
Authorized Principal Investigators planning to make a change to their
subregistration must fill out an X-ray Machine Subregistration Amendment Form
and send it to the RSO for review. This includes additions or deletions to the
subregistration.
The Radiation Safety Officer will submit all applications to the Radiation Safety
Committee for approval. The Radiation Safety Officer may give interim approval
to Principal Investigators until the next Radiation Safety Committee meeting.
When the RSO finds reason to give an interim authorization to a new PI prior to
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Radiation Safety Committee’s approval, the authorization will be limited to 90
days to allow sufficient time for a committee meeting (with quorum) to discuss and
then approve, deny, or issue conditionally a new subregistration to the PI. A
temporary subregistration permit with a 90 day expiration date will be issued with
the RSO’s signature until the Radiation Safety Committee approval is obtained. A
new permit will then be issued which includes the Chair’s signature.
Approved Principal Investigators will receive an Authorization Permit to work
with x-ray machines, which is proof of radiation authorization at the University of
Houston and may be submitted with Grant Proposals. Once authorized, the
Principal Investigator will remain authorized until either subregistration
termination by the Principal Investigator or the sublicense is revoked by the
Radiation Safety Committee for noncompliance.
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X­ray Machines and Other Ionizing Radiation Devices Procurement Procedures X-ray machines and other ionizing radiation producing devices can only be ordered
on a Purchase Requisition through the Purchasing Department per the University
of Houston Manual of Policies and Procedures (MAPP) 04.01.01. All Purchase
Requisitions for x-ray machines and other ionizing radiation producing devices
must be approved in advance by the Radiation Safety Officer. Transferred
equipment and donations must also be approved. The Radiation Safety personnel
will verify that Principal Investigators are authorized for the x-ray machines.
Purchase Requisitions may be brought to Environmental Health and Risk
Management located in the General Services Building, Room 183; faxed to 713743-8035; or mailed to EHRM-1005. Please call 713-743-5858 before bringing
orders over for approval to ensure the Radiation Safety Officer or representative
will be available to sign-off on your order. Every order should be accompanied by
an Addendum B per the Purchasing Department. Radiation Safety personnel will
stamp and sign each order. Normally orders will be promptly approved unless there
are some issues to be addressed. Purchasing Department will reject orders without
the Radiation Safety personnel’s approval. Also, Purchase Requisitions lacking
the necessary information, improperly filled out, or outside the Principal
Investigator’s authorization will be delayed.
X-ray safety devices should be purchased with the x-ray machine if possible, and
installed with the x-ray machine when received. Failure to plan and install safety
devices as required will delay the final approval for use of the x-ray machine.
Purchase Order information must include:
‰
‰
‰
‰
X-ray Machine, Type, Model and other pertinent information
(Only one X-ray Machine allowed per Purchase Requisition)
Brief Description or Copy of Brochure/Manual
Name of the Principal Investigator
Directions to deliver shipment
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X­ray Machines and Other Ionizing Radiation Devices Receipt, Setup, Documents, and Use The Radiation Safety Officer must be notified when an x-ray machine arrives and
when it is set up. The Radiation Safety Officer must document installation within
30 days of to maintain current registration information for the X-ray Registration..
Radiation Safety personnel will provide assistance to any Principal Investigator
who has special situations.
The Radiation Safety Officer will require specific documentation for review. All
records should be clearly identified, neatly organized, and kept together in one
location in the lab. This will enable Principal Investigators to meet regulatory
requirements and maintain compliance.
Normal Documentation • Equipment Manuals
• Purchase records*
• Receipt/Installation records* (Includes transfers or donations)
• Written stand alone operational procedures for each machine including startup, shut-down, safety device by-pass, alignment, and emergency *
• Calibration, maintenance, and modification records
• Safety devices (interlocks, warning lights, etc.)
• Other requested information
* Copies of these documents are required to be sent to the RSO at EHRM-1005.
Radiation Safety personnel will inspect the x-ray machine setup before operation
begins. The Principal Investigator may only turn on the x-ray machine for test
procedures in the initial setup. All safety devices must be installed and
operational. The x-ray machine must not be used without the final approval of the
Radiation Safety Officer. The Radiation Safety Officer will give final approval for
use upon full compliance.
X-ray machines must be inspected by Radiation Safety personnel at initial
installation, after a move, and whenever maintenance or modifications affect the
beam quality. It is the responsibility of the Principal Investigator to promptly
notify the Radiation Safety Officer. Door signage will always be supplied and
posted by Radiation Safety. Please call EHRM at 713-743-5858, if an x-ray
signage is missing or defaced.
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Radiation Safety Procedures f or the 1.7 MeV Particle Accelerator The University of Houston’s X-ray Safety Program sets forth controls and safety
guidance for research and educational activities involving accelerators. The
procedures herein are adapted from the regulations in Title 25 of the Texas
Administration Code (TAC), Chapter 289, Section 229. This program is
established to institute prudent safety practices and to meet the regulatory
requirements. If any conflict occurs between this program and the state regulations,
the latter shall prevail.
A radiation survey was conducted when the accelerator was first capable of
producing radiation to determine compliance. The initial survey and subsequent
surveys established that the accelerator facility is not a high radiation area and is
thus exempt from such requirements. Authorized Users work in the room at the
control panel near the accelerator where only background levels of radiation
exposure are measured. Additional radiation protection surveys will be performed
and recorded when changes have been made in shielding, operation, equipment, or
occupancy of adjacent areas.
OPERATING AND SAFETY PROCEDURES • No one shall be permitted to operate the accelerator unless such person has
received instruction in and demonstrated competence with
• the operating and safety procedures for the accelerator;
• Radiation warning and safety devices incorporated into the equipment and
the room;
• Identification of radiation safety hazards associated with the use of the
equipment;
• And, procedures for reporting an actual or suspected exposure in excess of
the limits.
• All Authorized Users including the Principal Investigator must attend and
pass the UH X-ray Safety Training Course. In addition, the Principal
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Investigator must provide all Authorized Users specific training in the use of
the accelerator and associated radiation hazards. Authorized Users must
know how to use the survey meters and alarm meters. A copy of the current
operating and the safety procedures shall be maintained near the accelerator
control panel.
• Authorized Use is limited to only those experimental procedures that
have been specifically approved by the Radiation Safety Officer. The
use of the accelerator is restricted to experimental procedures that do not
produce high radiation levels, generate neutrons, or create radioactive
materials at the target area due to the design and shielding limitations of the
facility. The particle accelerator installation is provided with such primary
and/or secondary barriers as are necessary to assure compliance. Some
barriers are mobile so that they can be strategically placed to minimize
radiation exposures. The Radiation Safety Officer has the authority to
terminate the operations at the particle accelerator facility if unapproved
experimental procedures are conducted.
• Instrumentation, readouts and controls on the particle accelerator control
console shall be clearly identified and easily discernible. The accelerator
area is equipped with an easily observable flashing, rotating warning light
that operates when radiation is being produced. This light can be seen
through the observation window prior to entry. The particle accelerator,
when not in operation, shall be secured to prevent unauthorized use. The
door to the room shall remain locked at all times.
• Authorized Users are issued radiation dosimeters and must wear them when
working around the accelerator. Visitors are issued direct reading pocket
dosimeters and a logbook of any readings is maintained. There are survey
meters available in the accelerator room for on-the-spot monitoring which
are calibrated on an annual basis. There is also a continuous x-ray/gamma
alarm monitor for the accelerator area. The alarm monitor is also calibrated
approximately annually. This monitor is required even though this is not a
high radiation area because of the potential radiation hazard of the
accelerator. They will alert users to any accidental misuse of the accelerator
which could result in high radiation levels. In addition, area monitors with
neutron chips are placed in strategic locations in the facility to augment all
other radiation monitoring.
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Basic X­ray Safety Guidelines Good Safety Practices Designated Responsible Operator Each lab should designate a primary responsible operator for the x-ray machines.
This person will be responsible for the interlock bypass keys and, perform the
alignments and equipment changes on the x-ray machines for the lab. This person
will also coordinate calibrations, repairs, and modifications of the equipment.
Authorized User Training All users are required to attend and pass the UH X-ray Safety Training Course.
Users must learn about basic x-ray safety practices and the protective devices
incorporated into each unit to minimize or prevent radiation exposures. In addition,
users need to be able to recognize protection system failures or other unusual
conditions that could lead to radiation exposures.
Operational Procedures Start up, shut down, alignment, and emergency procedures for all analytical x-ray
machines must be written and readily available. The safety and basic operations
sections in the manufacturer’s manual will include much of the necessary
information for the standalone document. Other x-ray machines classified as
minimal threat devices only require the availability of the manual for compliance.
Records X-Ray records are required to be maintained by all X-Ray PIs and readily available
for a state inspection. All records should be clearly identified, neatly organized,
and kept together in one central location in the lab.
Purchase records* Receipt/Installation records* (includes donations)
Written operating and safety procedures for analytical x-ray machines*
*
Copies of these documents are required be sent to Radiation Safety
Officer to be included in each X-Ray PI’s file.
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Equipment manuals
Calibration records (Where applicable)
Maintenance and modifications records (Where applicable)
Safety devices information (Interlocks, warning lights, etc.)
Engineering Protection Systems All interlocks, fail safe lighting, and shielding must be maintained and inspected at
each operation of the x-ray machines.
Personnel Monitoring and Equipment Survey Program Radiation Badges are supplied to primary users of x-ray diffraction machines and
other such potentially high exposure units. Survey meters are required for most
high exposure units. Radiation Safety personnel conduct required inspections of
all x-ray machines at the initial setup and after modifications, calibrations, and
moves. Radiation Safety personnel also perform routine inspections and exposure
surveys of the x-ray machines.
Signage All door signage is provided by Radiation Safety personnel to assure
standardization and compliance. A “Caution Safety Device Not Working” sign
must be used whenever the interlocks are bypassed for alignments and equipment
changes.
Equipment Safety Practices (Analytical Units) Ports All unused ports must be securely closed to prevent accidental opening.
Interlocks All interlocks on the x-ray machine must be functional and in operation for x-ray
production. Bypassing should only be performed by the designated responsible
operator and only during alignments and equipment changes as required.
Alignments Alignments should be performed at minimal settings and only by the designated
responsible operator. Only specially trained personnel should perform alignments.
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Maintenance Maintenance should only be performed by trained qualified individuals and at the
manufacturer’s recommended time intervals.
Warning Lights Analytical x-ray machine warning lights must have failsafe characteristics.
Beam Stops The x-ray beam must be terminated within the enclosure at all times.
Radiation Protection Practices Time The shorter the time spent around an x-ray exposure, the less the radiation dose.
Authorized users should minimize their exposures and keep their occupational
doses As Low As Reasonably Achievable (ALARA).
Distance Radiation levels decrease significantly with an increase of distance. The use of
distance is one of the easiest and most effective method for radiation protection.
Shielding Lead shielding should be used to reduce radiation levels to < 2 mR/Hr.
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Radiation Safety Requirements f or Analytical X­ray Machines and Other Industrial Radiation Machines The University of Houston’s X-ray Safety Program sets forth controls and safety
guidance for research and educational activities involving X-ray Machines. The
procedures herein are adapted from the regulations in Title 25 of the Texas
Administration Code (TAC), Chapter 289, Section 228. This program is
established to institute prudent safety practices and to meet the regulatory
requirements. If any conflict occurs between this program and the state regulations,
the latter shall prevail.
Equipment Requirements A safety device shall be provided on all open-beam configurations. A registrant
may apply for an exemption from the requirement of a safety device in accordance
with the TAC §289.231. Any such request shall include a description of the
various safety devices that have been evaluated; the reason each of these devices
cannot be used; and a description of the alternative methods that will be employed
to minimize the possibility of an accidental exposure, including procedures to
assure that operators and others in the area will be informed of the absence of
safety devices.
Warning Devices: Open-beam configurations shall be provided with a visible
indication of:
• x-ray tube status (ON-OFF) located near the radiation source housing, if the
primary beam is controlled in this manner; and/or
• shutter status (OPEN-CLOSED) located near each port on the radiation
source housing, if the primary beam is controlled in this manner.
The x-ray control shall provide visual indication whenever x-rays are produced.
Warning devices shall be labeled so that their purpose is easily identified and shall
have fail-safe characteristics.
Ports:
Unused ports on radiation machine source housings shall be secured in the closed
position in a manner which will prevent inadvertent opening.
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Labeling:
Each registrant shall ensure that each radiation machine is labeled in a conspicuous
manner to caution individuals that radiation is produced when unit is energized.
The label shall be affixed in a clearly visible location on the face of the control
un i t .
Shutters:
On open-beam configurations, each port on the radiation source housing shall be
equipped with a shutter that cannot be opened unless a collimator or a coupling has
been connected to the port.
Radiation source housing:
Each x-ray tube housing shall be equipped with an interlock that shuts off the tube
if it is removed from the radiation source housing or if the housing is disassembled.
Generator cabinet:
Each x-ray generator shall be supplied with a protective cabinet that limits leakage
radiation measured at a distance of 5 centimeters from its surface such that it is not
capable of producing a dose in excess of 0.5 millirem (5 microsieverts) in any one
hour.
There are additional considerations regarding Certifiable and Certified cabinet Xray systems as well as Package X-ray systems:
Certified x-ray systems, including those designed to allow admittance of
individuals shall
• Not be modified without prior approval of the Radiation Safety Officer and
the state agency.
• They shall not be operated by any individual without receiving a copy of,
and instruction in the operating procedures for the unit.
• The unit is to be tested for proper operation of the interlocks at intervals not
to exceed 12 months and the documentation provided for inspection,
• Also, the registrant is required to perform an evaluation to ensure radiation
emitted at 5 cm from the external surface of the unit does not exceed 0.5
millirem (5.0 microsieverts) in any one hour.
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• The registrant is required to maintain associated documentation from above
for 10 years for inspection by the agency.
Package x-ray systems require annual evaluations to ensure radiation levels emitted
at 5 cm from the external surface do not exceed 0.5 millirem per hour. Also, tests
for proper operation of interlocks shall be conducted and recorded at least annually
and the documentation and records maintained for state inspections for 10 years.
Area Requirements • The local components of an analytical x-ray system shall be located and
arranged, and shall include sufficient shielding or access control such that no
radiation levels exist in any area surrounding the local component group
which could result in a dose to an individual present in the area in excess of
the dose limits.
• Radiation surveys of all analytical x-ray systems sufficient to show
compliance with shall be performed upon installation of the equipment;
following any change in the initial arrangement, number, or type of local
components in the system; following any maintenance requiring the
disassembly or removal of a local component in the system; during the
performance of maintenance and alignment procedures, if the procedures
require the presence of a primary x-ray beam when any local component in
the system is disassembled or removed; any time a visual inspection of the
local components in the system reveals an abnormal condition; or whenever
personnel monitoring devices show a significant increase over the previous
monitoring period or the readings are approaching the radiation dose limits.
• Each area or room containing radiation machines shall be conspicuously
posted with a sign or signs bearing the radiation symbol and the words
“CAUTION - X-RAY EQUIPMENT,” or words having a similar intent.
Operating Requirements • Operating and safety procedures shall be written and available to all
radiation machine operators
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• No person shall be permitted to operate radiation machines in any manner
other than that specified in the procedures, unless that person has obtained
written approval of the Radiation Safety Officer.
• No person shall bypass a safety device unless such person has obtained the
approval of the Radiation Safety Officer. When a safety device has been
bypassed, a readily discernible sign bearing the words
“SAFETY DEVICE NOT WORKING,”
or words having a similar intent, shall be placed on the radiation source
h o u s in g .
Personnel Requirements No one shall be permitted to operate the radiation machine unless such person has
received instruction in and demonstrated competence with
o the operating and safety procedures for the radiation machine;
o Radiation warning and safety devices incorporated into the equipment
and the room;
o Identification of radiation safety hazards associated with the use of the
equipment;
o and procedures for reporting an actual or suspected exposure in excess
of the limits.
• All Authorized Users including the Principal Investigator must attend and
pass the UH X-ray Safety Training Course.
• The Principal Investigator must provide specific training for the use of the xray machine and associated radiation hazards.
• Authorized Users must know how to use a survey meter. A copy of the
current operating and the safety procedures shall be maintained near the xray machine.
• In addition to any assigned radiation dosimeters, finger badges shall be
provided to and shall be used by personnel maintaining analytical radiation
machines if the maintenance procedures require the presence of a primary x-
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ray beam when any local component in the x-ray system is disassembled or
removed.
Machine Security Radiation Machines shall be secured from unauthorized removal. Devices and/or
administrative procedures shall be used to prevent unauthorized use of radiation
machines.
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Radiation Safety Requirements f or X­ray Machines in the Healing Arts The University of Houston’s X-ray Safety Program sets forth controls and safety
guidance for research, educational and healing arts activities involving X-ray
Machines. The procedures herein are adapted from the regulations in Title 25 of
the Texas Administration Code (TAC), Chapter 289, and Section 227. This
program is established to institute prudent safety practices and to meet the
regulatory requirements. If any conflict occurs between this program and the state
regulations, the latter shall prevail.
Individuals shall not be exposed to the useful beam except for healing arts
purposes and unless such exposure has been authorized by a licensed practitioner
of the healing arts. Radiation Machines shall be secured from unauthorized
removal. Devices and/or administrative procedures shall be used to prevent
unauthorized use of radiation machines.
A technique chart relevant to the particular radiation machine shall be provided in
the vicinity of the control panel and used by all operators. Each registrant shall
have and implement written operating and safety procedures and the procedures
shall be made available to each individual operating a radiation machine including
any restrictions of the operating technique required for the safe operation of the
particular x-ray system. Written operating and safety procedures for the University
Houston Health Center are based on the Texas Department of State Health
Services’ Regulatory Guide 4.3-“Guide for the Preparation of Operating and Safety
Procedures for the Healing arts or Medicine, Podiatry and Chiropractic”
Dose Limitations All individuals who are associated with the operation of a radiation machine are
subject to the occupational dose limits of this title regarding dose limits to
individuals, and the personnel monitoring requirements of this title. Protective
devices shall be utilized when required. Protective devices shall be made of no
less than 0.25 mm lead equivalent material. Protective devices including aprons,
gloves, and shields shall be checked annually for defects, such as holes, cracks, and
tears. These checks may be performed by the registrant by visual or tactile means,
or x-ray imaging. If a defect is found, protective devices shall be replaced or
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removed from service until repaired. A record of this test shall be made and
maintained by the registrant for inspection by the agency.
Training and Certifications
Individuals who operate radiation machines for human use shall meet the
appropriate requirements of rules in accordance with the Medical Radiologic
Technologist Certification Act, Texas Occupations Code. A copy of the
credentialing document shall be maintained at the location where the individual is
working. Required surveys, tests, or evaluations that constitute the practice of
medical physics or as determined by the Radiation Safety Officer will require the
use of an outside consultant with a license from the Texas Board of Licensure for
Medical Physicists in accordance with the Medical Physics Practice Act, Texas
Occupations Code.
Access Restriction No individual other than the patient, operator, and ancillary personnel shall be in
the x-ray room or area while exposures are being made unless such individual's
assistance is required. When a patient or image receptor must be held in position
during radiography, mechanical supporting or restraining devices shall be used
when the exam permits. If a patient or image receptor must be held by an
individual during an exposure, that individual shall be protected with appropriate
shielding devices. The registrant's written operating and safety procedures shall
include a list of circumstances in which mechanical holding devices cannot be
routinely utilized; and a procedure for selecting an individual to hold or support the
patient or image receptor. In those cases where the patient must hold the image
receptor, any portion of the body other than of clinical interest struck by the useful
beam shall be protected by not less than 0.25 mm lead equivalent material.
Windows, mirrors, closed circuit television, or a method shall be provided to
permit operator to continuously observe the patient during irradiation. The
operator shall be able to maintain verbal, visual, and aural contact with the patient.
The operator position during the exposure shall be such that the operator's exposure
is as low as reasonably achievable (ALARA) and the operator is a minimum of six
feet from the source of radiation or protected by an apron, gloves, or other
shielding having a minimum of 0.25 mm lead equivalent material. In no case shall
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an individual hold the tube or tube housing assembly supports during any
radiographic exposure.
Gonadal shielding shall be used on patients when the gonads are in or within 5 cm
of the useful beam. This requirement does not apply if the shielding will interfere
with the diagnostic procedure. Gonadal shielding shall be of at least 0.5 mm lead
equivalent material.
The in-air exposure determined for the technique used for the specified average
human adult patient thickness for routine medical radiography shall not exceed the
entrance exposure shown in Table 1.
TABLE 1. RADIOGRAPHIC ENTRANCE EXPOSURE LIMITS ___________________________________________________________
Thickness
Exposure
(cm)
Limit (mR)
Technique
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Chest (PA)
(Non-Grid)
23
20
(Grid)
23
30
23
450
Abdomen (KUB)
Lumbo-Sacral Spine (AP)
23
550
Cervical Spine (AP)
13
120
23
325
Thoracic Spring (AP)
F u ll S p in e
23
300
15
150
Skull (lateral)
Foot (DP)
8
50
_ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
The technique factors to be used during an exposure shall be indicated before the
exposure begins except when automatic exposure controls are used, in which case
the technique factors that are set prior to the exposure shall be indicated. On
equipment having fixed technique factors there must be permanent markings. The
x-ray control shall provide visual indication of the production of x-rays. The
indicated technique factors shall be accurate to meet manufacturer's specifications.
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If these specifications are not available from the manufacturer, the factors shall be
accurate within plus or minus 10% of the indicated setting.
Films shall be developed in accordance with the time-temperature relationships
recommended by the film manufacturer. The specified developer temperature for
automatic processing and the time-temperature chart for manual processing shall
be posted in the darkroom. If the registrant determines that an alternate timetemperature relationship is more appropriate for a specific facility, that timetemperature relationship shall be documented and posted.
Chemicals shall be replaced according to the chemical manufacturer's or supplier's
recommendations or at an interval not to exceed three months. Darkroom light
tests shall be performed and any light leaks corrected at intervals not to exceed six
months. Lighting in the film processing/loading area shall be maintained with the
filter, bulb wattage, and distances recommended by the film manufacturer for that
film emulsion or with products that provide an equivalent level of protection
against fogging. Corrections or repairs of the light leaks or other deficiencies shall
be initiated within 72 hours of discovery and completed no longer than 15 days
from detection of deficiency unless authorized by the agency. Records of the
correction or repairs shall include the date and initials of the individual performing
these functions and shall be maintained for inspection by the agency.
Documentation that the registrant is following manufacturer's recommendations
shall be maintained at the site where performed.
A radiographic x-ray equipment performance evaluation shall be performed by a
contract Medical Physicist annually. Mechanical maintenance will be performed
by a vendor as required to maintain compliance. Quality assurance tests will be
performed by authorized personnel and vendors as required to maintain
compliance. In addition, Radiation Safety personnel will periodically perform
reviews to assure compliance.
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Radiation Safety Requirements f or X­ray Machines in Veterinary Medicine The University of Houston’s X-ray Safety Program sets forth controls and safety
guidance for research, educational, and veterinary medicine activities involving Xray Machines. The procedures herein are adapted from the regulations in Title 25
of the Texas Administration Code (TAC), Chapter 289, Section 233. This program
is established to institute prudent safety practices and to meet the regulatory
requirements. If any conflict occurs between this program and the state regulations,
the latter shall prevail.
OPERATING AND SAFETY PROCEDURES • No radiation may be deliberately applied to animals except by, or under the
supervision of a veterinarian authorized by the Texas Board of Veterinary
Medical Examiners to engage in veterinary medicine.
• Radiation Machines shall be secured from unauthorized removal. Devices
and/or administrative procedures shall be used to prevent unauthorized use
of radiation machines.
• A technique chart relevant to the particular radiation machine shall be
provided in the vicinity of the control panel and used by all operators.
• Each registrant shall have and implement written operating and safety
procedures. These procedures shall be made available to each individual
operating a radiation machine including any restrictions of the operating
technique required for the safe operation of the particular x-ray system.
Written operating and safety procedures for the Veterinary Facility are based
on the Texas Department of State Health Services’ Regulatory Guide 4.5.
• Except as otherwise exempted, all individuals who are associated with the
operation of a radiation machine are subject to the occupational dose limits
of this title regarding dose limits to individuals, and the personnel
monitoring requirements of this title.
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• Protective devices shall be utilized when required. Protective devices shall
be made of no less than 0.25 mm lead equivalent material. Protective
devices including aprons, gloves, and shields shall be checked annually for
defects, such as holes, cracks, and tears. These checks may be performed by
the registrant by visual or tactile means, or x-ray imaging. If a defect is
found, protective devices shall be replaced or removed from service until
repaired. A record of this test shall be made and maintained by the registrant
for inspection by the agency.
• No individual other than the animal, operator, and ancillary personnel shall
be in the x-ray room or area while exposures are being made unless such
individual's assistance is required. When an animal or image receptor must
be held in position during radiography, mechanical supporting or restraining
devices shall be used when the exam permits. If an animal or image receptor
must be held by an individual during an exposure, that individual shall be
protected with appropriate shielding devices. The registrant's written
operating and safety procedures shall include a list of circumstances in
which mechanical holding devices cannot be routinely utilized; and a
procedure for selecting an individual to hold or support the animal or image
receptor.
• The operator’s position during the exposure shall be such that the operator's
exposure is as low as reasonably achievable (ALARA) and the operator is a
minimum of six feet from the source of radiation or protected by an apron,
gloves, or other shielding having a minimum of 0.25 mm lead equivalent
material. In no case shall an individual hold the tube or tube housing
assembly supports during any radiographic exposure.
• The technique factors to be used during an exposure shall be indicated
before the exposure begins except when automatic exposure controls are
used, in which case the technique factors that are set prior to the exposure
shall be indicated. On equipment having fixed technique factors, there must
be permanent markings.
• The x-ray control shall provide visual indication of the production of x-rays.
The indicated technique factors shall be accurate to meet manufacturer's
specifications. If these specifications are not available from the
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manufacturer, the factors shall be accurate within plus or minus 10% of the
indicated setting.
Films shall be developed in accordance with the time-temperature relationships
recommended by the film manufacturer. The specified developer temperature for
automatic processing and the time-temperature chart for manual processing shall
be posted in the darkroom. If the registrant determines that an alternate timetemperature relationship is more appropriate for a specific facility, that timetemperature relationship shall be documented and posted. Chemicals shall be
replaced according to the chemical manufacturer's or supplier's recommendations
or at an interval not to exceed three months. Darkroom light tests shall be
performed and any light leaks corrected at intervals not to exceed six months.
Lighting in the film processing/loading area shall be maintained with the filter,
bulb wattage, and distances recommended by the film manufacturer for that film
emulsion or with products that provide an equivalent level of protection against
fogging. Corrections or repairs of the light leaks or other deficiencies shall be
initiated within 72 hours of discovery and completed no longer than 15 days from
detection of deficiency unless authorized by the agency. Records of the correction
or repairs shall include the date and initials of the individual performing these
functions and shall be maintained for inspection by the agency. Documentation
that the registrant is following manufacturer's recommendations shall be
maintained at the site where performed.
PERFOMANCE MAINTAINANCE & EVALUATION A radiographic x-ray equipment performance evaluation shall be performed by a
contract Medical Physicist annually. Mechanical maintenance will be performed
by a vendor as required to maintain compliance. Quality assurance tests will be
performed by authorized personnel and vendors as required to maintain
compliance. In addition, Radiation Safety personnel will periodically perform
reviews to assure compliance.
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Laser Subregistration Application and Amendment Guidelines All Class IIIb and IV lasers at the University of Houston must be approved by the
Radiation Safety Officer and authorized by the Radiation Safety Committee.
Only Class IIIb and IV lasers are required to be registered with the Texas
Department of State Health Services under the University of Houston’s Laser
Registration. Low power lasers including Class I, II and IIIa lasers are not required
to be registered.
New Principal Investigators (PIs) must fill out an Application for Laser
Subregistration and send it to EHRM-1005, for review by the Radiation Safety
Officer (RSO). Application forms can be found in the Radiation Safety Manual
located at http://www.uh.edu/plantops/ehrm. This subregistration application must
include all lasers, laser users, and equipment locations and procedures. Anyone
not listed on the subregistration permit must not be allowed to work with lasers for
any reason. The lasers must not be used until final approval is given by the RSO.
The use of lasers often requires specialized safeguards. Investigative procedures
vary widely as do applicable safety techniques. The information provided on the
application will enable the Radiation Safety Officer to formulate necessary safety
measures and assist the Principal Investigator in implementing these measures. It
is important that all pertinent information be included and the application fully
completed. Radiation Safety Personnel will perform a compliance inspection prior
to allowing laser use.
Authorized Principal Investigators planning to make a change to their
subregistration must fill out a Laser Subregistration Amendment Form and send it
to the RSO for review. This includes additions or deletions to the subregistration.
The Radiation Safety Officer will submit all applications to the Radiation Safety
Committee for approval. The Radiation Safety Officer may give interim approval
to Principal Investigators until the next Radiation Safety Committee meeting.
When the RSO finds reason to give an interim authorization to a new PI prior to
Radiation Safety Committee’s approval, the authorization will be limited to 90
days to allow sufficient time for a committee meeting (with quorum) to discuss and
then approve, deny, or issue conditionally a new subregistration to the PI. A
temporary subregistration permit with a 90 day expiration date will be issued with
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the RSO’s signature until the Radiation Safety Committee approval is obtained. A
new permit will then be issued which includes the Chair’s signature.
Approved Principal Investigators will receive an Authorization Permit to work
with lasers, which is proof of radiation authorization at the University of Houston
and may be submitted with Research Grant Proposals. Once authorized, the
Principal Investigator will remain authorized until either subregistration
termination by the Principal Investigator or the sublicense is revoked by the
Radiation Safety Committee for noncompliance.
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Lasers Procurement Procedures Class IIIb and IV lasers can only be ordered on a Purchase Requisition through the
Purchasing Department per the University of Houston Manual of Policies and
Procedures (MAPP) 04.01.01. All Purchase Requisitions for Class IIIb and IV
lasers must be approved in advance by the Radiation Safety Officer. Transferred
equipment and donations must also be approved. The Radiation Safety personnel
will verify that the Principal Investigators are authorized for the lasers.
Purchase Requisitions may be brought to Environmental Health and Risk
Management located in the General Services Building, Room 183; faxed to 713743-8035; or mailed to EHRM-1005. Please call 713-743-5858 before bringing
orders over for approval to ensure the Radiation Safety Officer or representative
will be available to sign-off on your order. Every order should be accompanied by
an Addendum B per the Purchasing Department. Radiation Safety personnel will
stamp and sign each order. Normally orders will be promptly approved unless there
are some issues to be addressed. Purchasing Department will reject orders without
the Radiation Safety personnel’s approval. Also, Purchase Requisitions lacking
the necessary information, improperly filled out , or outside the Principal
Investigator’s authorization will be delayed.
Laser safety devices should be purchased with the laser if possible, and installed
with the laser when received. Failure to plan and install safety devices as required
will delay the final approval for use of the laser.
Purchase Order information must include:
‰
‰
‰
‰
Laser, Type, Model and other pertinent information
(Only one Laser allowed per Purchase Requisition)
Brief Description or Copy of Brochure/Manual
Name of the Principal Investigator
Directions to deliver shipment
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Radiation Safety Requirements f or Class IIIb and IV Lasers The University of Houston’s Laser Safety Program sets forth controls and safety
guidance for research and educational activities involving lasers. The procedures
herein are adapted from the regulations in Title 25 of the Texas Administration
Code (TAC), Chapter 289, Section 301. This program is established to institute
prudent safety practices and to meet the regulatory requirements. If any conflict
occurs between this program and the state regulations, the latter shall prevail.
These requirements apply to lasers that operate at wavelengths between 180 nm
and 1 mm. All lasers and Intense-Pulsed Light (IPL) device use at the University
of Houston must be approved by the Laser Safety Officer and authorized by the
Radiation Safety Committee.
There are certain general prohibitions:
• Individuals shall not use lasers on humans unless under the supervision of a
licensed practitioner of the healing arts and unless the use of lasers is within
the scope of practice of their professional license.
• Individuals shall not be intentionally exposed to radiation above the
maximum permissible exposure levels (MPE) unless such exposure has been
authorized by a licensed practitioner of the healing arts.
• Exposure of an individual for training, demonstration or other non-healing
arts purposes is prohibited unless authorized by a licensed practitioner of the
healing arts.
• Exposure of an individual for the purpose of healing arts screening is
prohibited, except as authorized by the Texas Department of State Health
Services.
• Exposure of an individual for the purpose of research is prohibited, except as
authorized in research studies.
• Any research using radiation producing devices on humans must be
approved by an institutional review board (IRB) as required by the Code of
Federal Regulations. The IRB must include at least one practitioner of the
healing arts to direct use of the laser.
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Registration Requirements The university is required to notify the agency in writing within 30 days of any
increase in the number of lasers authorized by the Registration. Each new use of a
Class IIIb or Class IV laser in the healing arts or for animal use must be submitted
to the agency within 30 days after beginning operation of the laser. An application
for laser use in the healing arts shall be signed by a licensed practitioner of the
healing arts. Also, an application for veterinary medicine shall be signed by a
licensed veterinarian. .
No person shall make, sell, lease, transfer, or lend lasers unless such machines and
equipment, when properly placed in operation and used, shall meet the applicable
requirements. The university is required to inventory all Class IIIb and Class IV
lasers in their possession at an interval not to exceed one year.
The inventory shall be maintained for inspection and include:
Manufacturer’s Name
Model and Serial Number of the laser
Description of the laser
Location of the laser
The University is required to maintain records of receipt, transfer, and disposal of
all Class IIIb and Class IV lasers for inspection to include:
Manufacturer’s Name
Model and Serial Number of the laser
Date of receipt, transfer, and disposal
Name and address of person laser(s) received from, transferred to, or
disposed by,
Name of individual recording the information
Laser Safety Officer (LSO) duties The University Laser Safety Officer is a designated staff member who has the
knowledge and responsibility to apply appropriate laser radiation protection rules,
standards, and practices. The LSO is named and specifically authorized to perform
duties specified on the Certificate of Laser Registration issued by the Texas
Department of State Health Services, Bureau of Radiation Control. The duties of
the LSO include:
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• Ensure that users of lasers are trained in laser safety, as applicable for the
class and type of lasers the individual uses.
• Assumes control and has the authority to institute corrective actions
including shutdown of operations when necessary in emergency situations or
unsafe conditions.
• Specify whether any changes in control measures are required following any
service and maintenance of lasers that may affect the output power or
operating characteristics or whenever deliberate modifications are made that
could change the laser class and affect the output power or operating
characteristics.
• Ensure maintenance and other practices required for the safe operation of the
lasers are performed.
• Ensure the proper use of protective eyewear and other safety measures.
• Ensure compliance with the laser requirements and with any engineering or
operational controls specified by the university.
General Requirements f or protection against laser radiation These requirements are for Class IIIb and Class IV lasers in their intended mode of
operation and include special requirements for service, testing, maintenance, and
modification.
• In situations where engineering controls may be inappropriate, such as
medical procedures, the LSO shall specify alternate controls to obtain
equivalent laser safety protection.
• Each university or user of any laser shall not permit any individual to be
exposed to levels of laser or collateral radiation higher than the Maximum
Permissible Exposure (MPE) limits.
• Personnel operating each laser shall be provided with written instructions for
safe use, including clear warnings and precautions to avoid possible
exposure to laser or collateral radiation in excess of the MPE.
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Engineering Controls Protective Housing Each laser shall have a protective housing that prevents human access during the
operation of the laser and collateral radiation that exceeds the limits of Class I
laser.
Safety Interlocks A safety interlock, that shall ensure that radiation is not accessible above the MPE
limits, shall be provided for any portion of the protective housing that by design
can be removed or displaced during normal operation or maintenance, and thereby
allows access to radiation above the MPE limits.
Adjustment during operation, service, testing, or maintenance of a laser containing
interlocks shall not cause the interlocks to become inoperative or the radiation to
exceed MPE limits outside the protective housing except where a laser controlled
area is established.
For pulsed lasers, interlocks shall be designed so as to prevent firing of the laser;
for example, by dumping the stored energy into a dummy load.
For continuous wave lasers, the interlocks shall turn off the power supply or
interrupt the beam; for example, by means of shutters.
An interlock shall not allow automatic accessibility of radiation emission above
MPE limits when the interlock is closed. Either multiple safety interlocks or a
means to preclude removal or displacement of the interlocked portion of the
protective housing upon interlock failure shall be provided, if failure of a single
interlock would allow human access to high levels of laser radiation.
Viewing Optics and W indows All viewing ports, viewing optics, or display screens included as an integral part of
an enclosed laser or laser product shall incorporate suitable means, such as
interlocks, filters, or attenuators, to maintain the laser radiation at the viewing
position at or below the applicable MPE under any conditions of operation of the
laser.
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All collecting optics, such as lenses, telescopes, microscopes, endoscopes, etc.,
intended for viewing use with a laser shall incorporate suitable means, such as
interlocks, filters, or attenuators, to maintain the laser radiation transmitted through
the collecting optics to levels at or below the appropriate MPE. Normal or
prescription eyewear is not considered collecting optics.
Warning Systems Each class IIIb, or IV laser or laser product shall provide visual or audible
indication during the emission of accessible laser radiation. For Class IIIb lasers
except for those less than 5 mW peak visible laser radiation, and Class IV lasers,
this indication shall be sufficient prior to emission of such radiation to allow
appropriate action to avoid exposure. Any visible indicator shall be clearly visible
through protective eyewear designed specifically for the wavelength(s) of the
emitted laser radiation. If the laser and laser energy source are housed separately
and can be operated at a separation distance of greater than two meters, both laser
and laser energy source shall incorporate visual or audible indicators. The visual
indicators shall be positioned so that viewing does not require human access to
laser radiation in excess of the MPE.
Controlled Area For Class IIIb lasers, except those less than 5 mW visible peak power, or Class IV
lasers, a controlled area shall be established when exposure to the laser radiation in
excess of the MPE or the collateral limits is possible. Each controlled area shall be
posted by proper laser signage and access to the controlled area shall be restricted.
For Class IV indoor controlled areas, latches, interlocks, or other appropriate
means shall be used to prevent unauthorized entry into controlled areas.
Where safety latches or interlocks are not feasible or are inappropriate, for example
during medical procedures, the following shall apply:
• All authorized personnel shall be trained in laser safety and appropriate
personnel protective equipment shall be provided upon entry;
• A door blocking barrier, screen, or curtains shall be used to block, screen, or
attenuate the laser radiation at the entryway.
• The level at the exterior of these devices shall not exceed the applicable
MPE, nor shall personnel experience any exposure above the MPE
immediately upon entry.
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•
At the entryway there shall be a visible or audible signal indicating that the
laser is energized and operating at Class IV levels.
For Class IV indoor controlled areas, during tests requiring continuous operation,
the individual in charge of the controlled area shall be permitted to momentarily
override the safety interlocks to allow access to other authorized personnel if it is
clearly evident that there is no optical radiation at the point of entry, and if
necessary protective devices are being worn by the entering personnel.
For Class IV indoor controlled areas, optical paths from an indoor facility shall be
controlled in such a manner as to reduce the transmitted values of the laser
radiation to levels at or below the appropriate MPE and the collateral limits.
When the removal of panels or protective covers and/or overriding the interlocks
becomes necessary, such as for servicing, testing, or maintenance, and accessible
laser radiation exceeds the MPE and the collateral limits, a temporary controlled
area shall be established.
Key Control Each Class IIIb and Class IV laser shall incorporate a key-actuated or computeractuated master control. The key shall be removable and the Class IIIb and Class
IV laser shall not be operable when the key is removed. When not being prepared
for operation or is unattended, the key will be removed from the device and stored
in a location away from the machine.
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Additional Requirements f or Safe Operation Infrared Laser The beam from an infrared laser shall be terminated in a fire-resistant material
where necessary. Inspection intervals of absorbent material and actions to be taken
in the event or evidence of degradation shall be specified in the laboratory
operating and safety procedures.
Eye Protection Protective eyewear shall be worn by all individuals with access to Class IIIb and/or
Class IV levels of laser radiation. Protective eyewear devices shall provide a
comfortable and appropriate fit all around the area of the eye; be in proper
condition to ensure the optical filter(s) and holder provide the required optical
density or greater at the desired wavelengths and retain all protective properties
during its use; be suitable for the specific wavelength of the laser and be of optical
density adequate for the energy involved; have the optical density or densities and
associated wavelengths(s) permanently labeled on the filters or eyewear; and
examined, at intervals not to exceed 12 months, to ensure the reliability of the
protective filters and integrity of the protective filter frames. Unreliable eyewear
shall be removed from use and discarded.
Skin Protection When there is a possibility of exposure to laser radiation that exceeds the MPE
limits for the skin, the university shall require the appropriate use of protective
gloves, clothing, or shields.
Nominal Hazard Zone (NHZ) Where applicable, in the presence of unenclosed Class IIIb and Class IV laser
beam paths, an NHZ shall be established. If the beam of an unenclosed Class IIIb
and Class IV laser is contained within a region by adequate control measures to
protect personnel from exposure to levels of radiation above the appropriate MPE,
that region may be considered to be the NHZ.
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Caution Signs, Labels, and Posting f or Lasers The laser controlled area shall be conspicuously posted with a sign or signs as
specified by the regulations. The regulatory philosophy for laser postings and
labels are as well as the UH laser safety program is to notify individuals of the
hazards present. As such all access points to a laser facility with Class IIIb or
Class IV lasers must be marked with approved laser warning signs. Laser hazard
signs are available from the EHRM Department.
All signs and labels associated with Class II, IIIa, IIIb, and IV lasers shall contain
the following wording:
(A) The signal word "CAUTION" shall be used with all signs and labels
associated with all Class II lasers and all Class IIIa lasers that do not exceed the
appropriate MPE as in the figure below.
Sample Warning Sign for Class II and Class IIIa Lasers.
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(B) The signal word "DANGER" shall be used with all Class IIIa lasers that
exceed the appropriate MPE and all Class IIIb and IV lasers.
Sample Warning Sign for Class IIIb and Class IV Lasers
Equipment warning labels (see figure below) with the sunburst logo and the
appropriate cautionary statement will be conspicuously affixed to the laser housing
or control panel by the manufacturer. Laser enclosures must be labeled to alert
users to laser hazards. Labels are also available from the EHRM Department.
IEC Warning Logo and Information Label.
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Lasers, except lasers used in the practice of medicine, shall have a label(s) in close
proximity to each aperture through which is emitted accessible laser or collateral
radiation in excess of the limits with the following wording as applicable:
"AVOID EXPOSURE - Laser radiation is emitted from this aperture," if the
radiation emitted through such aperture is laser radiation.
"AVOID EXPOSURE - Hazardous electromagnetic radiation is emitted
from this aperture," if the radiation emitted through such aperture is
collateral radiation.
"AVOID EXPOSURE - Hazardous x-rays radiation is emitted from this
aperture," if the radiation emitted through such aperture is collateral x-ray
radiation.
Each non-interlocked or defeatably interlocked portion of the protective housing or
enclosure that is designed to be displaced or removed during normal operation or
servicing, and that would permit human access to laser or collateral radiation shall
have labels as follows:
Class IIIb accessible laser radiation, the wording; "DANGER - LASER
RADIATION WHEN OPEN. AVOID DIRECT EXPOSURE TO BEAM”.
Class IV accessible laser radiation, the wording; "DANGER - LASER
RADIATION WHEN OPEN. AVOID EYE OR SKIN EXPOSURE TO
DIRECT OR SCATTERED RADIATION”.
Collateral radiation in excess of the emission limits, the wording
"CAUTION - HAZARDOUS ELECTROMAGNETIC RADIATION
WHEN OPEN" and "CAUTION - HAZARDOUS X-RAY RADIATION."
as applicable.
For protective housings or enclosures that provide a defeatable interlock, the words
"and interlock defeated" shall be included in the labels.
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The word "invisible" shall immediately precede the word "radiation" on labels and
signs for wavelengths of laser and collateral radiation outside the range of 400 to
700 nm.
The words "visible and invisible" shall immediately precede the word "radiation"
on labels and signs for wavelengths of laser and collateral radiation that are both
within and outside the range of 400 to 700 nm.
Labels shall be clearly visible, legible, and permanently attached to the laser or
facility. Signs shall be clearly visible, legible, and securely attached to the facility.
Surveys Lasers inspections are conducted by Radiation Safety personnel to ensure
regulatory compliance at intervals not to exceed 12 months. The inspections
include a determination that all laser protective devices are labeled correctly, and
functioning within the design specifications, and properly chosen for lasers in use;
a determination that all warning devices are functioning within their design
specifications; a determination that the controlled area is properly controlled
and posted with accurate warning signs; a re-evaluation of potential hazards from
surfaces that may be associated with beam paths; and additional surveys that may
be required to evaluate the primary and collateral radiation hazard incident to the
use of lasers.
Records Radiation Safety will maintain compliance records for regulatory review.
Applicable records must be submitted by the Laser PI or designated personnel to
the Radiation Safety upon request.
Injury or Medical Event Each PI shall immediately seek appropriate medical attention for the injured
individual and notify the LSO by telephone of any exposure injury involving a
laser possessed by the university.
The LSO shall be notified within 48 hours of any non-injury incident (near miss)
which involves potential exposure to laser radiation exceeding the MPE. A written
summary of an injury or non-injury incident shall be forwarded to the LSO no later
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than five (5) working days following the incident. Records of any incident shall be
maintained by the Principal Investigator.
The LSO shall, within 24 hours of discovery of an injury, report to the agency each
injury involving any laser possessed by the university, other than intentional
exposure of patients for medical purposes, that may have caused, or threatens to
cause, an exposure to an individual with second or third-degree burns to the skin or
potential injury and partial loss of sight.
The LSO shall make a report in writing to the agency within 30 days and a notice
to the individual shall be transmitted at the same time. The LSO shall also notify
the agency of any medical event involving a patient as required.
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Basic Laser Safety Guidelines Measures necessary for controlling laser hazards normally concentrate upon
making the beam path inaccessible, such as enclosing the laser in a box or
controlled room to prevent unauthorized access. As this is not always possible,
other Administrative and Engineering Controls are used to lessen the possibility of
in ju r y .
The Safety Procedures necessary for any laser operation vary with 3 aspects:
‰ Laser hazard classification
‰ Environment where the laser is used (outside vs. inside a controlled area)
‰ People operating or within the vicinity of the laser beam (Desks in lab)
Safety procedures are best presented by relating them to the laser hazard class.
All laser products above Class I, manufactured after August 1976, must have labels
that indicate the class to which they belong. FDA Regulatory Standard for all
lasers divides laser products into 4 classes, based on the potential for injuring
people and the intensity of the radiation in the laser beam (power of beam
measured in watts).
Laser Classifications (ANSI Z136.1) Class I - Exempt Lasers
‰
‰
‰
Produce levels of radiation that have not been found to cause biological
damage
This group is normally limited to gallium-arsenide lasers or certain enclosed
lasers
Incorporated into consumer or office machine equipment
Safety Precautions
‰ No laser specific rules, however general lab safety rules still apply
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Class II
- Low power and low risk
‰ Produce radiation that could cause eye damage after direct, long term
exposure
‰ Hazardous only if viewer overcomes natural aversion response to bright
light and continuously stares into source (Natural aversion response is the
movement of the eyelid or the head to avoid an exposure to a noxious
stimulant or bright light and can occur within 0.25 sec). Like blinding
oneself by forcing oneself to stare at the sun for more than 10 to 20 seconds.
Safety Precautions
‰ Never permit a person to stare into the laser source
‰ Never point the laser at an individuals eye
Class IIIa – Low Risk or Medium Power
‰
Higher irradiance than Class II lasers with danger safety precautions
requiring strict adherence to safety precautions.
Safety Precautions
‰ Never permit a person to stare into the laser source
‰ Never point the laser at an individuals eye
‰ Operate the laser only in a controlled area
Class IIIb - Moderate Risk or Medium Power
‰
‰
‰
Produce radiation powerful enough to injure human eye tissue with 1 short
exposure to the direct beam or its direct reflections off a shiny surface.
Does not produce hazardous diffuse reflections under normal use,
Not usually capable of causing serious skin injury.
Safety Precautions
‰ Do not aim the laser at an individual’s eye
‰ Permit only experienced personnel to operate the laser
‰ Enclose the beam path as much as possible.
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‰
‰
‰
‰
‰
‰
‰
‰
Even a transparent enclosure will prevent individuals from placing their
head or reflecting objects within the beam path
Termination should be used at the end of the useful paths of the direct and
any secondary beams
Operate the laser only in a restricted area
Place the laser beam path well above or well below the eye level of any
sitting or standing observers whenever possible
The laser should be mounted firmly to assure that the beam travels only
along its intended path
Always use proper laser eye protection for the direct beam or a specular
reflection
Key switch to prevent tampering by unauthorized individuals
Remove all unnecessary mirror-like surfaces from within the vicinity of the
laser beam path
Class IV - High Power, High risk of injury and can cause combustion of
flammable materials.
‰
May also cause diffuse reflections that are eye hazards and may also cause
serious skin injury from direct exposure
Safety Precautions
‰ Class IIIb safety precautions and;
‰ Should only be operated within a localized enclosure or in a controlled
workplace
‰ If complete local enclosure is not possible, Interlocking of room
‰ Eye wear is needed for all individuals working within the controlled area
‰ Backstops should be diffusely reflecting - fire resistant target materials
ANSI Z136.1 emphasizes that “It must be recognized that this classification
scheme relates specifically to the laser device and its potential hazard, based on
operating characteristics. However, the conditions under which the laser is used,
the level of safety training of persons using the laser, and other environmental and
personnel factors are important considerations in determining the full extent of
safety control measures.”
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Lasers Receipt, Setup, Documents, and Use The Radiation Safety Officer must be notified when a laser arrives and when it is
set up. The Radiation Safety Officer must document installation within 30 days of
to maintain current registration information for the Laser Registration.. Radiation
Safety personnel will provide assistance to any Principal Investigator who has
special situations.
The Radiation Safety Officer will require specific documentation for
review. All records should be clearly identified, neatly organized, and kept
together in one location in the lab. This will enable Principal Investigators to meet
regulatory requirements and maintain compliance.
Normal Documentation ‰ Equipment Manuals
‰ Purchase records*
‰ Receipt/Installation records* (Includes transfers or donations)
‰ Written stand alone operational procedures for each Class IIIb and IV laser
including start-up, shut-down, safety device by-pass, alignment, and
emergency *
‰ Calibration, maintenance, and modification records
‰ Safety glasses
‰ Safety devices (interlocks, warning lights, etc.)
‰ Other requested information
* Copies of these documents are required to be sent to the RSO at EHRM-1005.
Radiation Safety personnel will inspect the laser setup before operation begins.
The Principal Investigator may only turn on the laser for test procedures in the
initial setup. All safety devices must be installed and operational. The laser must
not be used without the final approval of the Radiation Safety Officer. The
Radiation Safety Officer will give final approval for use upon full compliance.
Lasers must be inspected by Radiation Safety personnel at initial installation, after
a move, and whenever maintenance or modifications affect the output. It is the
responsibility of the Principal Investigator to promptly notify the Radiation Safety
Officer. Door signage will always be supplied and posted by Radiation Safety
personnel. Please call EHRM at 713-743-5858, if laser signage is missing, defaced
or needs updating.
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GLOSSARY OF TERMS Absorbed Dose - The amount of energy absorbed as a result of ionizing radiation
passing through a material per unit mass of material. Measured in Rads (R) and
Gray(Gy).
Absorption- Process by which energy from radiation is transferred to matter by
interactions with the constituents of the matter. A result is a reduction in the
intensity of the radiation also known as Attenuation.
Accessible Laser Radiation – Proximity to radiation that is not blocked by an
intervening barrier or filter.
Activity - The strength of a radioactive source, the number of radioactive atoms
decaying per unit of time. See RADIOACTIVITY. The units of activity are
disintegrations per minute (dpm), Curie (Ci), or Becquerel (Bq).
Alara (As Low As Reasonably Achievable) -Each individual makes every
reasonable effort to maintain occupational and public exposure to radiation as low
as practical.
ALARA Dose Levels - Levels of personnel dose above which require a review of
radioactive material and radiation source use and procedures to determine if doses
may reasonably be reduced.
Alpha Particle - A particle which is identical to the helium nucleus, consisting of
two protons and two neutrons. It has a charge of +2 and is the least penetrating of
the three common types of ionizing radiation. It is usually a hazard only when the
alpha emitting substance has entered the body.
Analytical radiation machine - This includes, but is not limited to x-ray
equipment used for x-ray diffraction, fluorescence analysis, spectroscopy, or
particle size analysis.
Animal Waste, Remains or Carcasses - Any related waste, resulting from
animals that have been dosed with radioactive material, such as bedding, urine,
feces, other fluids, tissue, or carcass. All waste from a dosed animal shall be
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handled as radioactive material until proven otherwise by the Radiation Safety
personnel.
Annihilation radiation- Photons produced when a particle and its antiparticle
interact and annihilate each other. The photons have energy of 0.511 MeV each.
Aperture - An opening through which radiation can pass.
Atomic Number - The number of protons in the nucleus of an atom. The number
of protons determines what an atom is chemically, and, hence, identifies it as
belonging to a certain chemical element.
Atomic weight- Number approximately equal to the total number of protons and
neutrons in the nucleus of an atom i.e. the mass of an atom.
Attenuation - The process by which a beam of radiation is reduced in intensity
when passing through some material. It is the combination of absorption and
scattering processes and leads to a decrease in intensity of the beam.
Audit - A thorough examination of an entire program. An audit may include a
survey and an inspection.
Authorized User (AU) - Individuals who are granted the privilege and
responsibilities of receiving, possessing, using, and transferring radioactive
material under a specific sublicense granted at the University of Houston. All PIs
are also considered Authorized users.
Avalanche­ The buildup of ionization by electrons produced in a G-M tube by the
primary ionization as electrons drift toward the collector. The electrons gain
energy when traveling toward the collector and in the last few mean free paths of
the collector, undergo collisions producing secondary ionizations.
Background­ In measurements, the count obtained in the absence of a sample due
to instrument noise, cosmic radiation, as well as other sources of radiation.
Background Radiation - Radiation from cosmic sources; naturally occurring
radioactive materials, including radon (except as a decay product of source or
special nuclear material) and global fallout as it exists in the environment from the
testing of nuclear explosive devices.
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Backscatter- Reflection of radiation back in the direction of the detector as a
result of interactions occurring in the sample holder, the sample itself or the sample
backing material.
Beam - A collection of rays characterized by direction, diameter (or dimensions),
and divergence (or convergence).
Becquerel (Bq) - The SI unit of measurement of radioactivity equal to one
disintegration per second. One Becquerel is equal to 2.7 x 10-11 Ci.
Beta Particle- A negatively charged particle that is emitted by certain radioactive
atoms. A beta particle is identical to an electron.
"Biodegradable" or "Environmentally Friendly" Scintillation Cocktail - A
liquid scintillation fluid used for liquid scintillation analysis that has a flash point
greater than 300 °F or 150 °C.
Bioassay - The determination of kinds, quantities or concentrations, and, in some
cases, the locations of radioactive materials in the human body, whether by direct
measurement (in vivo counting) or by analysis and evaluation of materials excreted
or removed from the human body.
Biological half­life - Time required for a biological system to eliminate one-half
of an amount of substance that has entered it.
Bremsstrahlung Radiation – Secondary electromagnetic radiation (x-rays)
produced by deceleration of charged particles through matter.
Collateral Radiation - Any electromagnetic radiation, except laser radiation,
emitted by a laser that is physically necessary for its operation.
Compliance -To act in accordance with, and meet the responsibilities of
regulatory requirements and University of Houston’s Radiation Safety Program
procedures.
Compton effect- A collision between a photon and an electron in which the
photon is scattered at a reduced energy and the electron which gains kinetic energy
in the collision is ejected from the atom.
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Contamination – See Radioactive Contamination
Continuous Wave - The output of a laser that is operated in a continuous rather
than a pulse mode (Greater than or equal to 0.25 seconds).
Controlled Area - An area where the occupancy and activity of those within is
subject to control and supervision for the purpose of protection from radiation
hazards.
Curie (Ci) - The basic unit of activity corresponding to a disintegration rate of 3.7
x 1010 disintegrations per second. One curie is the approximate activity of 1 gram
of radium.
Dead time- The time interval after a pulse has occurred during which the detector
system is insensitive to further ionizing events.
Decay constant- The fraction of the number of atoms of a radioactive nuclide
which will decay in unit time interval.
Decay, radioactive- Spontaneous change in the state of nuclide to another energy
state of the same nuclide or into a different nuclide. Usually involves the
emission of particles or photons.
Declared Pregnant Woman - A woman who has voluntarily informed her
employer, in writing, of her pregnancy and the estimated date of conception.
Decontamination - Removal of radioactive contamination from where it is
deposited. Soap and water is good decontaminant agent.
Detector- Material or device that is sensitive to radiation and can produce a
signal suitable for measurement or analysis.
Disintergration- See DECAY, RADIOACTIVE.
Dose Limits - The limits of personnel dose set by the regulatory authorities which
cannot be exceeded in a period or calendar year.
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Dose Rate - In radiation safety, a measurement of radiation absorbed by various
parts of the human body over a period of time. Dose rate is documented in millirem
per hour (mrem/hr).
Dosimeter (Personnel) - A radiation measuring devices worn by personnel to
measure dose to various parts of the body. It is worn in the form of a badge or
finger ring. Film badge, TLD, OSL or pocket ionization chambers are some
examples.
Efficiency – As applied to a counting device or radiation detecting equipment is
the ratio of radiation detected to radiation emitted and is specific for each
radioisotope and geometry.
Electromagnetic Radiation - Radiation consisting of electric and magnetic fields
traveling at the speed of light (i.e., light, x-rays, gamma rays). Familiar
electromagnetic radiations range from x-rays and gamma-rays of short wavelength,
through the ultraviolet, visible and infrared regions, to radar, and radio waves of
relatively long wavelength. The ionizing electromagnetic radiations are gamma
rays and x-rays.
Electromagnetic Radiation – The flow of energy consisting of orthogonally
vibrating electric and magnetic fields lying transverse to the direction of
propagation. X-ray, ultraviolet, visible, infrared, and radio waves occupy portions
of the electromagnetic spectrum and differ only in frequency, wavelength, or
photon energy.
Electron capture - Radioactive decay of a nuclide in which an orbital electron is
captured by the nucleus, forming a new nuclide with the same atomic weight but an
atomic number reduced by 1.
Electron- Elementary particle with a unit a negative electrical charge and mass
1/1837 that of the proton. Positive electrons are called positrons.
Electron Volt (eV) - Customary unit for expressing the energy of ionizing
radiation. One eelectron volt is equal to the kinetic energy gained by an electron
passing through a potential difference of one volt.
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Embryo/Fetus - The developing human organism from conception until the time
of birth. More accurately, first 2 weeks-embryo (when implantation occurs), after 8
weeks- fetus.
Energy - The capacity for doing work expressed in joules (J) usually to describe
pulsed lasers.
Environmental Health and Risk Management Department (EHRM) – UH
department which includes the Radiation Safety Office and is additionally
responsible for establishing compliance criteria and monitoring for Environmental
Management Section, Hazardous Material Management, Occupational Health,
General Safety and Risk Management.
Excited state - The state of an atom, molecule, nucleus, or electron when it
possesses more than its normal energy.
Fail safe- describes a device or feature which, in the event of failure, responds in a
way that will cause NO harm or danger, or at least a minimum of harm to
personnel and other devices connected to it.
Fail­safe characteristics - Design features that cause beam port shutters to close,
or otherwise prevent emergence of the primary beam, upon the failure of a safety
or warning device.
Film badge- A device consisting of photographic film and a holder which is used
to determine the radiation exposure of the person wearing the device. The holder
contains filters which allow determination of the energy of the radiation exposing
the film.
Fixed Contamination - Contamination, generally on a surface, which cannot be
removed by any known usual decontamination cleaning methods. The type of
contamination which can be removed is termed removable contamination.
Fluorescence- Absorption of radiation and the reemission of radiation at the
same or a different wavelength.
Formal Training - Classroom type training conducted by a radiation safety
training program or a college credit course on radiation related topics. Documen91
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tation is required for radiation safety training received from a program other than
the UH Radiation Safety Training Program or for college credit courses.
Gamma Radiation or Gamma­Ray - Electromagnetic radiation originating from
the nucleus of an atom as a result of transformation occurring within the nucleus.
A very penetrating radiation and must be shielded with a very dense material.
Gamma rays are identical to x-rays, but have a nuclear origin, rather than an atomic
o r ig in .
Gieger­Muller counter- An ionization chamber, operating in the Geiger region,
used to measure and detect radiation and radioactivity, Also called a GM counter.
Gray (Gy) - The SI unit of absorbed dose. One gray is equal to an absorbed dose of
1 J/kg or 100 rad. i.e. the absorption of I Joule of radiation energy by 1 Kg of
tissue.
Half Life (T1/2) - The time required for one-half the atoms of a particular
radioactive substance to decay into another substance.
Half­life, EFFECTIVE­ Time required for a radionuclide contained in a biological
system to reduce its activity by half as a result of physical decay and biological
elimination.
Half­Value Layer- Thickness of any absorber required to reduce the intensity of a
beam of radiation (X or gamma rays) to one-half its original intensity. Synonym
for half-value thickness.
High Energy Beta particle - A beta emitted with maximum energy greater than 1
MeV. For e.g., beta energy fromP-32 emitted at 1.71 MeV.
Inactive Status – A PI who is on inactive status remains authorized, but does not
possess any radioactive material or source of radiation and all authorized
radioactive material use areas are closed out. To reactivate the authorization, the PI
must, along with the Radiation Safety Officer or designated personnel, conduct a
review of the authorization, review any changes in the Authorization, and
reactivate approved radioactive material or radiation use areas. The authorization
must be reactivated prior to receipt of radioactive material.
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Incident - An occurrence that either results in an item of non-compliance or could
have led to an item of non-compliance if the occurrence had not been identified.
Informal Training - On-the-job-type training; typically on authorization for specific
procedures.
Infrared Radiation - Electromagnetic radiation with wavelengths that lie within
the range of 700 nm to 1 mm.
Interim Approval - Authorization issued by the RSO prior to final review and
approval of the authorization applications by the RSC. Interim approval is usually
given for a period, not to exceed 90 days.
Inventory of Radioactive material- A documented list recording the receipt,
use, transfer, decay and disposal of radioactive material so that the amount,
location and disposition of the radioactive material received under the
authorization may be determined at any point in time.
Ion Pair- A positive ion and an electron or negative ion produces by an ionizing
event.
Ionization Chamber- Instrument used to detect and measure ionizing radiation
by measuring the electrical current that flows when radiation ionizes gas or air in a
chamber, making the gas or air a conductor of electricity.
Ionization- Process of adding or removing electrons from atoms or molecules,
creating ions.
Ionizing Radiation - Any radiation which ionizes atoms or molecules (i.e., alpha,
beta, gamma).
Irradiance – Radiant power incident per unit area upon a surface, expressed as
watt per square centimeter (W/cm-2).
Isotope- One or more atoms of the same element but with different atomic
weights. Nuclei of isotopes have the same number of protons but with different
number of neutrons. Thus, Carbon-12, Carbon-13 and Carbon-14 are isotopes of
the element carbon, the numbers denoting the atomic mass number. Isotopes have
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very nearly the same chemical properties, but often different physical properties
(for example, carbon-12 and -13 are stable, carbon-14 is radioactive).
Joule - A unit of energy equal to one watt-second.
keV- Symbol for kilo-electron volt of 100 eV.
Labeling - Marking items to inform other personnel of the presence of, or areas
which contain items that are potentially contaminated with radioactive materials.
Laser – An electronic device that emits stimulated radiation to energy density
levels that could reasonably cause bodily harm. The term “laser” also includes the
assembly of electrical, mechanical, and optical components associated with the
laser.
Leak Test – A contamination survey, performed on a sealed source to ensure that
the integrity of the source containment is maintained. Sealed Sources that are
found to be leaking must be removed from service. Leak tests are usually
conducted by Radiation safety personnel and any abnormally will be
communicated to the PI.
License - The document issued by the State of Texas permitting the University of
Houston to receive, possess, utilize, transfer, or dispose of specific byproduct,
source, or special nuclear materials. Currently, UH is licensed under a Broad Scope
License from the Texas Department of State Health Services.
License Conditions - A requirement established specific to UH license which can
only be changed through a license amendment issued by the State of Texas. Failure
to meet a license condition, like failure to meet Federal Regulations, will most
likely result in an NRC violation, possible civil penalty (monetary fine), and
possible criminal prosecution.
Linear Energy Transfer (LET) - The rate of energy transfer per unit distance
along a charged-particle track.
Liquid Waste - Radioactive waste in liquid form. This waste may be unwanted
radioactive stock solutions, liquid waste from radioactive procedures, or used
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liquid scintillation cocktail. In the case of liquid scintillation cocktail used for wipe
tests, they are to remain in the vials and not to be poured out.
Local components of x­ray system - Parts of an x-ray system that include areas
that are struck by x-rays such as radiation source housings, port and shutter
assemblies, collimators, sample holders, cameras, goniometers, detectors, and
shielding, but do not include power supplies, transformers, amplifiers, readout
devices, and control panels.
Low Energy Beta - A beta emitted with maximum energy less than or equal to
300 keV. Typical examples of radionuclide giving off this form of energy include
C-14 and H-3.
Luminescence- Emission of light produces by interactions of radiation with
certain chemical or materials.
Maximum Permissible Exposure (MPE) - The level of laser of collateral
radiation to which a person may be exposed without hazardous effect or adverse
biological changes in the eye or skin.
Mean Free Path- The average distance traveled by a particle, atom or molecule
between collisions or interactions.
Mean Life- The average life of a radioactive atom. It is equal to the reciprocal of
the decay constant or 1.44 times the half-life.
Member of the Public - Any individual that does not work with or around a
source of radiation.
MeV- Symbol for one million electron volts or 1000 kilo electron volts, keV.
Minimal threat radiation machines: include, but are not limited to,
fluorescence x-ray (closed bean), gauges x-ray, certified cabinet x-ray, package xray, electron beam welding, particle size analyzer, ion implant, and cathodoluminesence. In addition, minimal threat radiation machines are those machines
capable of generating or emitting fields of radiation that, during the operation of
which no deliberate exposure of an individual occurs, the radiation is not emitted in
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an open beam configuration; and no known physical injury to an individual has
occurred.
Minor – is considered an individual less than 18 years of age.
Monitoring - An assessment of current radiological conditions performed during
the work period. This includes the periodic checks for contamination or radiation
levels on the hands, clothing, floor and immediate work area using appropriate
survey instrumentation.
Neutrino- An electrically neutral elementary particle with a negligible mass.
Accounts for that part of beta decay energy not associated with the emitted beta
particle.
Neutron- An uncharged elementary particle with a mass slightly greater than that
of the proton, found in the nucleus of atoms.
Nominal Hazard Zone - The space within which the level of direct, reflected, or
scattered radiation during operation exceeds the applicable MPE.
Nuclide- A species of atom characterized by the makeup of its nucleus. The atom
must exist for a measurable length of time.
Occupational Dose - Dose received by an individual in the course of
employment in which the individual's assigned duties involve exposure to radiation
or radioactive material from licensed and unlicensed sources of radiation, whether
in the possession of the licensee or other person. Occupational dose does not
include dose received from background radiation, from any medical procedure the
individual has received, or, from exposure to individuals administered radioactive
material through medical procedures and released in accordance, from voluntary
participation in medical research programs, or as a member of the public.
Open­beam configuration - A radiation machine in which an individual could
accidentally place some part of his/her body in the primary beam path during
normal operation.
Optical Density - The logarithm to the base ten of the reciprocal of the
transmittance.
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Other industrial radiation machines - This includes, but is not limited to, xray equipment (including cabinet x-ray equipment) used for cathodoluminescence,
ion implantation, gauging, or electron beam welding.
Pair Production- An absorption process for x and gamma radiation in which the
incident photon is annihilated in the vicinity of the nucleus of the absorbing atom.
As a result of the interaction, an electron-positron pair is produced. The incident
energy of the photon must be greater than 1.022 MeV.
Personnel Monitoring - Measurement of personnel dose through the use of
personnel dosimeters, air samples, bioassays, radiation surveys or any combination
of the above with related calculations.
Personnel Protective Equipment (PPE) -Equipment designed to maximize the
control of radioactive material or to minimize dose or contamination. This includes
but is not limited to safety glasses, lab coats, gloves, face shields, etc.
Photoelectric Effect- An inelastic collision between a photon and an orbital
electron n which the electron is ejected from the atom.
Photoelectron- The electron ejected from an atom as a direct result of an
interaction with a photon.
Photon - A quantum (or packet) of energy emitted in the form of electromagnetic
radiation. Gamma rays and x-rays are examples of photons.
Positron - An elementary particle with the mass of an electron but unit positive
charge.
Posting - The conspicuous placing of signs, notices, announcements, procedures,
etc. in and around restricted areas that inform individuals of the types of
precautions they must take. Posting are required by regulations and are done by
radiation safety personnel.
Primary beam - Ionizing radiation which passes through an aperture of the
source housing by a direct path from the x-ray tube located in the radiation source
h o u s in g .
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Proportional Counter- A radiation detector which produces an output pulse
proportional in amplitude to the energy of the incident radiation.
Protective Housing - An enclosure surrounding the laser that prevents access to
laser radiation above the applicable MPE level.
Proton- An elementary nuclear particle with a single positive electrical chargethe nucleus of an ordinary or light hydrogen atom. All nuclei of all atoms contain
p r o to n s .
Pulse Duration - The duration of a laser pulse.
Pulsed Laser - A laser that delivers its energy in the form of a single pulse or a
train of pulses.
Quality Factor (Q) - A numerical factor assigned to describe the average
effectiveness of a particular kind (and sometimes energy) of radiation in producing
biological effects in the human. The quality factor is used to derive equivalent dose
from absorbed dose.
Rad - The special unit of absorbed dose. One rad is equal to an absorbed dose of
100 ergs/g or 0.01 J/kg or 0.01 gray. This unit applies to any type of ionizing
radiation absorbed in any material. If material is not specifically stated, then tissue
is assumed.
Radiation – The emission and propagation of energy by means of photons or high
speed particles. As used in this manual, radiation refers to ionizing radiation, such
as x-ray, gamma, alpha, beta and neutron.
Radiation Area - An area, accessible to individuals, in which radiation levels
could result in an individual receiving a dose equivalent in excess of 5 mrem in 1
hour at 30 cm from the radiation source or from any surface that the radiation
penetrates.
Radiation Emergency Procedures - Procedures established to define the types of
immediate actions to take in case of emergency to regain control of radioactive
materials and prevent any additional spread of contamination.
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Radiation Safety Committee (RSC) - The group established by regulation and
license conditions responsible for overseeing the UH Radiation Safety program and
controlling the use of radioactive materials and other sources of radiation under the
UH broad scope authorization/ license.
Radiation Safety Manual (RSM) - This document describes the UH Radiation
Safety Program responsibilities, duties, and procedures which need to be
understood and followed by the PIs and AUs. It is an enforceable component of the
UH Radiation Safety Program.
Radiation Safety Officer (RSO) - As required by regulations, this individual is
responsible for the implementation of the UH Radiation Safety Program. This
individual ensures that radiation safety activities are performed in accordance with
RSC policy, approved procedures, and regulatory requirements in the daily
operation of the UH Radiation Safety Program.
Radiation Safety Program - The program established by the UH Broad Scope
License, administered by the RSO, as authorized by the RSC and UH
Administration to ensure safe use of radiation sources at the University of Houston.
Radiation Safety Program Procedures - General overall procedures established
and monitored by the RS Office to ensure compliance with regulatory
requirements, license conditions and institutional policies established by the
Radiation Safety Committee and UH Administration.
Radioactive Contamination- Radioactivity deposited on any material or structure
where it will become a health hazard or source of radiation.
RADIOACTIVE DECAY- See DECAY, RADIOACTIVE.
Radioactive Material - Material that decay by emitting ionizing radiation. These
are radioactive materials approved in the UH license and radioactive materials
registered with the State of Texas.
Radioactivity - The spontaneous decay of an excited atomic nucleus usually
accompanied by the emission of ionizing radiation.
Radioisotope- An unstable isotope of an element that decays or disintegrates
spontaneously, emitting radiation.
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Radiotoxicity- Term referring to the potential of an isotope to cause damage to
living tissue by absorption of energy from the disintegration of the radioactive
material introduced into the body.
REM (ROENTGEN EQUIVALENT MAN) – A unit dose of any ionizing
radiation which produces the same biological effect as a unit of absorbed dose of xrays. The dose in REMs is equal to the product of the dose in RADs times a
quality factor.
Removable Contamination - Contamination which can be removed or spread by
something coming in contact with the contaminated surface.
Roentgen (R) - A unit of exposure to ionizing radiation. It is that amount of
gammas or x-rays required to produce ions carrying one electrostatic unit of
electrical charge in one cubic centimeter of dry air under standard conditions.
Named after Wilhelm Roentgen, German scientist who discovered x-rays in 1895.
Safety device - A device which prevents the entry of any portion of an individual’s
body into the primary x-ray beam path or which causes the beam to be shut off
upon entry into its path.
Scintillation Counter- An instrument that detects and measures ionizing radiation
by counting and analyzing the photons produced by absorption of radiation in
certain materials.
Sealed Source - Radioactive material that is permanently bonded or fixed in a
capsule or matrix designed to prevent release and dispersal of the radioactive
material under the most severe conditions likely to be encountered in normal use
and handling. Sealed sources are registered by the manufacturer through the
Nuclear Regulatory Commission, NRC.
Self-absorption- The absorption of radiation by the radioactive substance itself.
Shield (Radiation Shield) - Material used to absorb radiation and protect
personnel form radiation exposure.
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Sievert (Sv) - The SI unit of any of the quantities expressed as dose equivalent.
The dose equivalent in Sieverts is equal to the absorbed dose in gray multiplied by
the quality factor. (1 Sv = 100 rem).
Solid Waste - Primarily paper, plastic, glass, or gloves which are potentially
contaminated with radioactive material.
Specific Activity- The activity of a radioisotope per unit mass of the sample.
Spectrum- A visual display or plot of the distribution of the intensity of a given
type of radiation as a function of its energy or some other quantity.
Spill- An accidental release of radioactive material.
State or Regulatory Inspection - An examination of procedures, records, safety
issues, and personnel performance, including comparison of AU and RS Office
data and records. An inspection generally includes a survey and is typically
conducted by EHS or the NRC.
Stock vial or Source vial - Radioactive material in the container originally
supplied by the vendor.
Sublicense - The privilege to receive, possess, use, and transfer radioactive
material under UH Broad Scope License.
Sublicense Amendment – An amendment to sublicense application as above
submitted by an approved PI to the Radiation Safety Committee to amend certain
information contained in the approved sublicense.
Sublicense Application - Information provided by the prospective PI to the
Radiation Safety Committee in support of receiving the privilege of authorization.
Information must include- personal data; isotopes, form, and amounts requested;
type of use; special radiation safety procedures required; waste generation;
restricted area(s), modifications, and facilities; instrumentation; training;
experience; and administration support.
Surface Contamination Survey - Radiation level readings taken at one cm from
the surface with open detector window.
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Survey - An evaluation of the radiological conditions and potential hazards
incident to the production, use, transfer, release, disposal, or presence of
radioactive material or other sources of radiation. When appropriate, such an
evaluation includes a physical survey of the location of radioactive material and
measurements or calculations of levels of radiation, or concentrations or quantities
of radioactive material present.
Survey Meter- A hand held portable radiation detection instrument designed for
surveying or monitoring an area for the presence of or contamination with
radioactive material.
Termination of Sublicense - Means that no radioactive materials are possessed
(including any contaminated supplies, waste or equipment). All approved areas are
closed out and all procedure/approvals under the sublicense are terminated.
Thermoluminescent Dosimeter (TLD)- A device used to measure the radiation
dose to an individual wearing the device. The device contains a small amount of
LiF which absorbs energy from radiation and when heated will reemit the energy
in the form of light. The emitted light is measured by a PMT.
Transfer of Radioactive Material - Change in possession of any radioactive
material from one authorization to another or from an authorization to another
licensee.
Transmission - Passage of radiation through a medium.
Ultraviolet Radiation - Electromagnetic radiation with wavelengths smaller than
those of visible radiation; for the purpose of these rules 180 to 400 nm.
Unauthorized personnel - Any personnel or visitor who is not authorized or
trained to work with radiation sources under any sublicense.
Visible Radiation - Electromagnetic radiation that can be detected by the human
eye with wavelengths that lie in the range of 400 to 700 nm.
Watt - The unit of power or radiant flux equal to 1 joule per second.
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Wavelength - The distance between two successive points on a periodic wave that
have the same phase.
X-ray- Electromagnetic radiation emitted when orbital electrons of an excited
atom return to their ground or normal state. X-rays are also emitted when high
speed electrons strike a metal target. Electromagnetic rays that are produced as the
result of deceleration of charged particles as they pass near the nucleus are called
continuous x-rays (Bremsstrahlung). X-rays are identical to gamma rays, but
originate outside the nucleus.
X-ray system - A group of components utilizing x-rays to determine the elemental
composition or to examine the microstructure of materials.
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