Radiation Safety Regulation

Version 1 (Current Version)
All Versions:
  • Version 1
TitleRadiation Safety Regulation
CategoryHealth Affairs
Sub-categoryHealth Affairs Matters - General
AuthorityVice Chancellor for Health Sciences

Initial 1991. Last review 2010; Placed in University Policy Manual after EXPEDITED REVIEW, transitioned without substantive change from prior version, January 29, 2013.


Director, Office of Prospective Health or Radiation Safety Officer, 744-2070

Related Policies
Additional References

Prospective Health

Prospective Health/Radiation

10 CFR 20 10 CFR 35 NC RPAR 15A NCAC 11

1. Introduction

1.1. The University Radiation Safety Program is established to ensure safe use, handling, and possession of radiation sources in compliance with federal and state regulations.

1.2. Purpose:

1.2.1. Whenever and wherever sources of radiation are used, the safety of faculty, staff, students, and the general public and the immediate and general environment will be protected.

1.2.2. Exposure of personnel and the public from ionizing and non-ionizing radiations will be limited to a level As Low As Reasonably Achievable (ALARA), not to exceed federal and state regulations.

1.2.3. All work will be conducted in compliance with state and federal regulations.

1.3. Scope:

This regulation applies to:

1.3.1. All personnel: faculty, staff, students, visitors, contractors, patients, and members of the public.

1.3.2. All facilities and settings (clinical, research, teaching) owned, leased or controlled by the University.

1.3.3. The ordering, receipt, possession, installation, use, or disposal of radioactive materials, radioisotopes, sources, radiopharmaceuticals and devices or equipment which generates ionizing radiation and some forms of non-ionizing radiation.

2. The Radiation Safety Program consists of the Radiation Safety Officer and Radiation Safety Section of the Office of Prospective Health, and the Radiation Safety Committee(s): Basic Science and Clinical.

2.1. The Radiation Safety Officer manages the Radiation Safety Program on a day to day basis, conducts general surveillance of all radiation safety related activities, ensures that the University meets all regulatory and licensing obligations, regulations, and standards and interfaces with regulatory agencies.

2.1.1 The Radiation Safety Section is comprised of technical staff and administrative assistants, who support and implement the overall day-to-day operation of the radiation safety program.

2.2. The Radiation Safety Committee potentially consists of two subcommittees: Basic Sciences and Clinical.

2.2.1. Each subcommittee is chaired by a faculty member from a relevant discipline, experienced in the use of radiation or radioactive materials.

2.2.2. Each subcommittee is comprised of faculty and staff from departments using radiation in research (Basic Science) or healthcare (Clinical).

2.2.3. Each subcommittee oversees the responsible use of radiation in accord with the safety regulations set by the University and by State and Federal requirements. It provides input and technical advice on scientific applications and on administrative processes, reviews the credentials of users to ensure sufficient training and experience to perform the activities proposed, reviews instances of alleged infractions of safety rules and takes necessary steps to prevent or correct or such occurrences.

2.3. Radiation Safety Operation

2.3.1. Operations include training, technical monitoring and measurements, recordkeeping, response to spills or other adverse events, shipping, receiving and tracking of all radioactive materials and implementing a radioactive waste disposal program.

2.3.2. Where unsafe practices or practices in violation of established regulations are observed, the RSO is authorized to immediately suspend any operation causing excessive and/or unnecessary radiological hazard; to report the situation to regulatory agencies as required; to subject the situation to review by the relevant Radiation Safety Committee, and to inform University administration.

2.3.3. The Committee may prohibit further use until satisfactory safety procedures have been adopted.

3. Radiation Safety Standard Operating Procedures (Radiation Safety Manual)
Specific, detailed information on personnel rights and responsibilities, training, monitoring, procedures and facilities requirements are outlined in the Radiation Safety Standard Operating Procedures also known as the Radiation Safety Manual.

3.1. This manual provides guidance for laboratories and individuals using Radioactive Materials or Radiation-generating devices.

3.1.1. Contains reference materials and links to develop project-specific Radiation Safety standard operating procedures,

3.1.2. Outlines the proper handling, treatment and disposal of radioactive materials, radioactive wastes, sources, radiation-generating devices and contaminated equipment.

3.1.3. Describes the steps to be taken in the case of spills or other emergencies,

3.1.4. Outlines the responsibilities of all parties involved in obtaining and using radiation.

3.2. Changes to the Radiation Safety Manual.

3.2.1. The manual is modified as regulations or regulatory enforcement procedures change, to clarify administrative processes, to address problem areas or development of new technology and to reflect evolution of best practices.

3.2.2. Changes will be initiated by the Radiation Safety Section, reviewed and approved by the Radiation Safety Committee, and posted online on the University webpage.