UAB Radiation Safety Procedure Manual, 9Th Edition, 2007
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August 31, 2007 To Whom It May Concern: This manual was developed with the assistance of the Occupational Health and Safety staff, the Radioisotope & Radiation Safety Committee, and appropriate legal counsel and is published as the official policy of the University of Alabama at Birmingham for radiation studies and the activities surrounding those studies. Adherence to the procedures, practices, and recommendations described herein is essential if the University is to meet its obligation of providing a safe and healthful environment for study, training, and investigative pursuits. Many of our research and educational activities utilize ionizing radiation. Their success very much depends on the thoughtfulness and care exercised by every individual involved with the program. The UAB Department of Occupational Health and Safety is hereby charged with the responsibility of ensuring that the University of Alabama at Birmingham is in compliance with the provisions stated in this manual and other appropriate state, county, and federal radiation control regulations. All faculty, staff, employees, and students engaged in work involving radioactive materials or radiation- producing devices are expected to be familiar with and comply with the policies presented in this manual. Sincerely, Carol Z. Garrison President University of Alabama at Birmingham Radiation Safety Procedures Manual Ninth Edition 2007 2 TABLE OF CONTENTS I. Introduction....................................................................................... 5 II. ALARA – A Management Concept......................................................... 6 III. Radioisotope & Radiation Safety Committee................................ 7 IV. Radioactive Drug Research Committee......................................... 11 V. Subcommittee of Laboratory Use on Electronic Product Radiation........................................................................................... 14 VI. Radiation Safety Program................................................................ 21 VII. Responsibilities of Department Chairmen, Deans, and Administrators.................................................................................. 27 VIII. Responsibilities of Licensee.............................................................. 27 IX. Responsibilities of Individual User................................................... 30 X. Liability Aspects of Working with Radioactivity and Radiation Equipment.......................................................................... 31 XI. Instrument Calibration....................................................................... 32 XII. Surveys of Radioisotope and Radiation Use..................................... 32 XIII. Personnel Monitoring......................................................................... 36 XIV. Storage of Radioactive Material....................................................... 42 XV. Posting and Labeling......................................................................... 42 XVI. Procurement of Radioactive Materials.............. .............................. 43 XVII. Procedures for Working with Radioactive Material and Radiation Equipment................................................................... 45 XVIII. Use of Radionuclides in Experimental Animals.............................. 46 XIX. Emergency Procedures...................................................................... 47 XX. Transfer of Radioactive Material....................................................... 49 XXI. Disposal of Radioactive Material........................................................ 50 XXII. Sources of Concern.......................................................................... 52 3 APPENDICES A. UAB Radiation Safety Committees...................................................………….. 53 B. Criteria for Approval of Human Use Studies in Radioactive Drug Research................................................................………….. 55 C. Instructions for Operators of Particle Accelerators...................................... ..................................................…………. 57 D. Guide for External Radioisotope Monitoring....................................……….….. 58 E. Guide for Internal Radiochemical Monitoring..................................……….….. 61 F. Liquid Collection Technique to Minimize Spills and Contamination.............................................................................……….….. 77 G. Area Warning Signs, DOT Shipping Labels, and Radioactive Waste Tags............................................................……………. 78 H. Radioactive Waste Management.......................................................……………. 79 1. Radioactive Waste Minimization, A Mandatory Program (Supplement A).........................................................…………… 84 2. Methods Utilized by Licensee in A Radioactive Waste Minimization Program (Supplement B)... .............................…………… 85 I. Criteria for Approval of Radioisotope Licensure and Use.......................................................................................……….… 86 1. Nonhuman Use Criteria...............................................................…………… 86 2. Human Use Criteria.......................................................................………….. 87 3. Responsibilities & Supervision (Supplement A)………………………….… 89 4. Handling Techniques (Supplement B).......................................……………. 91 J. Criteria for Ventilation Design.......... ...............................................……………. 93 1. Criteria for Radiochemical Culture Work in Class II Type A Biosafety Cabinets (Supplement A)..........................................................................…………. 99 K. Radiation Dose Disclosure Form.........................................................………….. 101 L. Quarterly Report Form on Human Use Radioactive Drug Research............................................................................................………….... 103 M. Schedule of Deminimus Levels of Radioactivity... ........................…………….. 104 N. UAB Policy Regarding Radiation Exposure During Pregnancy ..…………….. 115 Pregnancy Precautions in Nuclear Medicine ………………………………….. 119 Pregnant Worker’s Guide ..............................................................…………… 120 Instructors Guide .............................................................................…………… 123 Effects of Risk Factors on Pregnancy Outcome...........................…………….. 125 Pregnancy Instruction Statement……………………………………………… 127 O. Radiation Safety Audit Schedule and Escalated Enforcement Actions....................................................……………… 128 P. Procedures for Therapy Treatment With Unsealed Radiopharmaceuticals……. 131 Q. Procedures for Therapy Treatment With Sealed Radiopharmaceuticals………. 139 R. Radiation Safety Terms and Definitions........................................…………….. 143 S. Accepted Half-lives Of Commonly Used Radioisotopes……………………… 150 4 I. Introduction In a comparatively short period of time, the University of Alabama at Birmingham has gained recognition as a center of excellence for teaching, medical services, and research programs. This is a highly commendable achievement and one that could not have been realized without the continued support and dedication of faculty, staff members, and employees. Similar unfailing cooperation and support is necessary for the institution to be equally successful in its development of a comprehensive occupational health and safety program for protection of university personnel, students, and the community. An important part of this program is concerned with safety in research studies and safe disposal of laboratory wastes, including radioisotopes and radiotoxic chemicals. The Department of Public Health for the State of Alabama has granted UAB a broad radioactive materials license and other licenses authorizing the use of radioactive materials. A radioactive materials license of broad scope is issued to institutions that perform a variety of tasks with many different radionuclides. Prior to receiving such a license, an institution must have previously demonstrated that it has the knowledge, resources, and capability for using these materials safely. The UAB Radioisotope and Radiation Safety Committee (RRSC), which is composed of individuals knowledgeable in the various applications of radiation, administers the activities conducted under this license. This committee must approve in advance the manner in which all radioactive materials are licensed, purchased, stored, used, transferred, and disposed. At UAB, there is one other committee which has responsibilities in radiation protection as it applies to human use research with radioactive drugs. This is the Subcommittee for Human Use (SCHU). In addition, the staff of the Radiation Safety Program provides advice and assistance in solving radiological safety problems. It also has the responsibility for evaluating the use of radioisotopes and other radiation sources throughout the University. Any findings and recommendations are discussed with the principal investigator and reported to the appropriate committee. This manual is part of the broad radioactive materials license granted UAB by the State of Alabama, and, as such, cannot be changed without the approval of the UAB RRSC and the Office of Radiation Control, Alabama Department of Public Health. Its purpose is to describe the operation of the radiation safety program and to provide