REGISTRATION AND APPROVAL FOR USE OF X-RAY EQUIPMENT AND SEALED
RADIOACTIVE SOURCES (QM_OHSD_SE009_April 2012)
Please return this form and a copy of the experimental protocols to College RPO, Occupational Health and Safety
Directorate, 404 Bancroft Road, Mile End, E1 4NS. (http://qm-web.safety.qmul.ac.uk/)
For Office use only
Project approval date
……/……../20…..
Project Number
Project review date
.…../…….../20…..
Project reapplication date
……/…….../20….
NOTE: All sections of this form must be completed, including attachments requested, before project approval will be
given.
Are the following attached?
Y/N
Experimental protocol
Laboratory plan
Photographic Images of Equipment/Sources
Section 1 - The Equipment/Source Location
Mile End
Whitechapel
Charterhouse Square
West Smithfield
*Other
Department /School / Centre and Institute
Building and Room Number
Section 2 – Experimental Procedures
Describe procedures in which the equipment/source will be used (Describe the source as it is to be used.
Specify any attached apparatus and shielding, safety interlocks or other precautions)
Will patients or healthy volunteers be irradiated?
If yes has the work ethics approval* (IRMER details required in Section 2 below) and ARSAC
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
1
Section 3 – Personnel Involved
Radiation Protection Supervisor
Telephone number
e-mail address
Centre/Institute / School / Department
Equipment/Source Supervisor
Telephone number
e-mail address
Centre/Institute / School / Department
*IRMER Practitioner/Operator
Telephone number
e-mail address
Centre / Institute / School / Department
Personnel working with the X-ray equipment/sealed source
Name
Academic/Technician/Post- Radiation Safety
doc/PhD student/Other
(X-ray and
sealed source)
Course Attended
Y/N
Date attended
Signed
declaration
that local
rules read and
understood
Y/N
Section 4a – X-Ray Source
Make
Model
Serial Number
Type
( Attach Photo of Unit)
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
2
Maximum operating kV
Maximum operating mA
Yes
No
Remote Interlock (Y/N)
Key Control
Mains on indicator
Beam on indicator
Beam Shutter
Signage
Shielded enclosure
Detail routine dose rate monitoring
available in laboratory
Section 4b – Sealed Source Description
Isotope
Supplier
Serial/Identifier Number
IsoStock Reference
Activity (MBq)
Activity date
Principle radiation
( ,  )
Date purchased
Permitted within Fixed Condition
Registration Category 5 permit
(No)
A/D Value
Within Site Permit Total limit
Other Exemption/Permit
Place stored
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
3
Wipe test record
Physical description including
dimensions
(Attach photo (JPEG) of each
source with source ID in filename)
Section 5 – Facilities and Documentation
Attach a plan of the laboratory indicating X-ray and/or radiation work areas
Security and storage: Give details of the building and radioactive lab security for storage of
radioactive sources
Give details of fire safety (smoke detectors etc) in the radioactive work and storage areas
Detail maintenance arrangements for X-ray and wipe/leak test arrangements for sources
Radiation Monitoring Equipment Available
Monitor and probe
Serial Numbers
Last calibration date
Suitable for X-ray
generator or
radionuclides in use?
Section 6 – Radiation Risk Assessment
Attach a copy of the experimental protocol, which must include instructions / methods on keeping doses to
personnel as low as reasonably practicable
Radiation Hazards
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
4
Justification for Use
Best practical means (BPM) of reducing exposure to radiation must be used: describe the means by
which this will be achieved *
Persons at risk (persons carrying out the work and persons potentially at risk e.g. cleaners,
maintenance personnel)
Control measures in place to keep prevent exposure (using ALARP and BAT principles) of groups
named above
Monitoring measures: Personal and Environmental
Risk Assessment performed by:
Position:
Date:
RPS Signature (if not person above):
Date:
THIS DOCUMENT MUST BE REVIEWED ANNUALLY OR WHEN SIGNIFICANT CHANGES IN PRACTICE
HAVE OCCURRED OR AUDIT SHOWS THAT A REVIEW IS NECESSARY.
To be completed by RPS
Is the risk assessment satisfactory?
Section 7 – Approvals (please obtain signatures in order below)
Name:
Date:
Signature:
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
5
Agreement by Equipment/Source Supervisor
I agree to inform the College RPO within the Occupational Health and Safety Directorate and the RPS of any
changes to the experimental procedures as set out in this document including changes in personnel. I agree
to comply with the College Local Rules and any other conditions which the RPA recommends as a condition of
granting approval for this project.
Name:
Date:
Signature:
Head of School or Department/Centre Lead*
Name:
Date:
Signature:
RPA
Name:
Date:
Signature:
NB: The College RPO within the Occupational Health and Safety Directorate and RPS must be informed
immediately of any personnel or material changes in protocol or activities or radio-nuclides used in this project.
* The Centre Lead signs on behalf of the Director of Institute.
Experiment Protocol

All students will be given appropriate training and supervision

Students will not be given any sources until they have indicated that they are ready to use them

Only one source will be given to each set of equipment at any one time

The time each student spends on the experiment will be limited to six hours

Radioactive sources will be locked away when the experiment is not in use
Laboratory Plan
Photographic Images of Equipment/Sources
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
6
Document Control
Version No.
Date of alteration and reissue
1
01 May 2007
Details of changes
Changes made by
Original Version
(QM/H&S/0073)
-
2
21 Sep 2011
Updated –added Sealed source
Fixed Condition Registration
considerations
3
April 2012
Filename Path Changed from
H&S0073
QM_OHSD_SE009_April 2012_Sealed Source X-ray Approval Form
Radiation Protection Safety SubCommittee
Darren Ford
7