TULANE UNIVERSITY MEDICAL CENTER

1430 TULANE AVENUE

NEW ORLEANS, LA 70112

REVIEWED AND APPROVED
09 SEPTEMBER 1997
LOUISIANA LICENSE NO.: LA-0004-L01
Chairman, Radiation Safety Committee
Radiation Safety Officer

TABLE OF CONTENTS

I. Objectives of Radiation Protection

III. Radiation Safety Officer

IV. Guidelines for Nuclear Medicine Activities Involving Technicians & Other Paramedical Personnel

V. Routine for Ordering, Receiving,Opening Packages Containing Radioactive Material; Procedure for Documenting Use of Material.

VI. Instructions for Administration of Radiopharmaceuticals for Diagnostic and Therapeutic Procedures

VII. Laboratory Rules for Use of Radioactive Material

VIII. Restriction and Labeling of Radiation Areas

IX. Personnel Monitoring Policy

XI. Radiation and Contamination Area Surveys

XII. Decontamination Procedures

XIII. Contaminated Equipment

XIV. Emergency Procedures

XVI. Instructions for Housekeeping

XVII. Escort Personnel

XVIII. Instructions for Visitors

XIX. Storage of Radionuclides

XXII. Safety Rules: Fixed Fluoroscopic

XXIII. Safety Rules: Operators of Mobile Radiographic Equipment

XXIV. Safety Rules: Operators of Mobile Fluoroscopic Equipment

XXV. Safety Rules: Persons in the Vicinity of Mobile X-Ray Equipment

XXVI. Specific Instructions for Allied Medical Workers

XXVII. Radiation and Pregnancy, Radiation and Allied Medical Staff

XXVIII. Diagnostic Radiology and the Pregnant Patient

XXIX. Patient Pregnancy Screening

XXX. Nuclear Medicine and the Pregnant Patient

XXXI. Quality Control Procedures

XXXIV. Procedure for Monitoring and/or Checking Trap Effluent

APPENDIX

APPENDIX A. Radiation Safety Committee

APPENDIX B. Technologists Approved For Radionuclide Injection

APPENDIX C. Daily Incoming/Outgoing Shipment Inspection Log

APPENDIX D. Radionuclide Distribution

APPENDIX E. Dose Calibrator Calibration Record

APPENDIX F. Radionuclide Decay-In-Storage/Disposal Form

APPENDIX G. Instrument Maintenance and Repair Record

APPENDIX H. Radiation History Request Form

APPENDIX I. Film Badge Monitoring Service Request

APPENDIX J. Notice to Employees

APPENDIX K. Effective Dose Equivalent Limit Recommendations

APPENDIX L. Model Program for Maintaining Occupational Radiation Exposure at Medical Institutions ALARA

APPENDIX M. Standards for Protection Against Radiation

APPENDIX N. Diagnostic And/Or Therapeutic Procedure Misadministration Report

APPENDIX O. Therapeutic Radionuclide Consultation Form

APPENDIX P. Quality Management Program

APPENDIX Q. Quality Management Program

APPENDIX R. Quality Management Checklist for Administration of ¹²⁵I, ¹³¹I Activities Greater than 30mCi

APPENDIX S. Instructions for Brachytherapy

APPENDIX T. Operating Room Care: Brachytherapy Sources

APPENDIX U. Nursing Care, Brachytherapy Sources/Radiopharmaceutical Therapy

APPENDIX V. Radionuclide Therapy Survey

APPENDIX W. Activities and Dose Rates For Authorizing Patient Release

APPENDIX X. Activities and Dose Rates Above Which Instructions Should
Be Given When Authorizing Patient Release

APPENDIX Y. Activities of Radiopharmaceuticals That Require Instructions And
Records When Administered To Patients Who Are Breast-Feeding An Infant or Child

APPENDIX Z. Home Instruction: Radiopharmaceutical Therapy

APPENDIX AA. Home Instructions

APPENDIX BB. ⁹⁰Sr Opthalmic Applicator Therapy

APPENDIX CC. Instructions For Family of Released Patient

APPENDIX DD. Report of Radioactivity of Cadaver

APPENDIX EE. Instructions To Funeral Director For Embalming Body Containing Radioactive Material

APPENDIX FF. Autopsy Or Surgery Precautions

APPENDIX GG. Mammography Requirements

APPENDIX HH. Authorization Use of Radioactive Materials

APPENDIX II. Authorization to Use Radionuclides: Research Facilities/Laboratories

APPENDIX JJ. SI Units For Radiation Protection

APPENDIX KK. Units And Definitions

APPENDIX LL. Management Of Victims Of Radioactive Contamination

APPENDIX MM. Condensed Research Laboratory Rules
 

A. General
 

The specific objectives of radiation protection are: (1) to prevent, to the extent practicable, the occurrence of severe radiation-induced nonstochastic diseases by adhering to dose equivalent limits that are below the apparent practical threshold dose equivalent levels; and (2) to limit risk of the stochastic effects, fatal cancer and genetic effects, to a reasonable level in comparison with non-radiation risks and in relation to societal needs, benefits gained and economic factors. These objectives are achieved by applying individual dose equivalent limits for occupational and nonoccupational (general public) exposures.
 

It is emphasized that for the purposes of radiation protection, a cautious assumption is made, the reliability of which has not been established. This is the assumption that the dose-risk relationship is strictly proportional (linear) without threshold throughout the range of radiation protection. Furthermore, doses and the probability of response (risk) are assumed to accumulate linearly. At higher doses, received acutely, such as in accidents, more complex (non-linear) dose-risk relationships may apply.
 

Under these assumptions, any selected dose equivalent limit will have an associated level of risk. Tulane University Medical Center endorses the following: (1) the need to justify any activity which involves radiation exposure on the basis that the expected benefits exceed the predicted cost (justification); (2) the need to reduce the total radiation detriment from such justifiable activities or practices to AS LOW AS IS REASONABLY ACHIEVABLE (ALARA), economic and social factors being taken into account and (3) the need to apply individual effective dose equivalent limits to ensure that the procedures for justification and ALARA do not result in individuals or groups of individuals exceeding levels of acceptable risk.
 

B. ALARA
 

Tulane University Medical Center is committed to keeping exposures ALARA. The Radiation Safety Committee (RSC) will perform an annual review of the radiation safety program. This shall include review of summaries of the types and amounts of radioactive material used, occupational dose reports, and continuing education and training for all personnel who work with or in the vicinity of radioactive material. The purpose of the review is to ensure that individuals make every reasonable effort to maintain occupational doses, doses to the general public and releases of radioactive material ALARA, taking into account the state of technology and the cost of improvements in relation to benefits. Modification to operating procedures or to equipment and facilities will be made where they will reduce exposures unless the cost is considered to be unjustified. In addition to maintaining doses to individuals as far below the limits as is reasonably achievable, the sum of the doses received by all exposed individuals will also be maintained at the lowest practicable level.
 

The RSC will delegate authority to the Radiation Safety Officer (RSO) for enforcement of the ALARA concept.
 

The RSC will support the RSO in those instances where it is necessary for the RSO to assert his authority. Where the RSO has been overruled, the RSC will record the basis for its action in the minutes of the RSC's quarterly meeting.
 
 

ALARA LEVELS

Investigational Levels (mrems per calendar quarter)
 

Level I Level II
 

Whole body; head and trunk; 125 375

active blood-forming organs;

lens of eye; gonads
 

Hands and forarms; feet and 375 1125

ankles
 

Skin of whole body* 1250 3750
 

*Not normally applicable to nuclear medicine operations except those

using significant quantities of beta emitting nuclides.
 
 
 
 

The following actions will be taken at the Investigational Levels stated in the ALARA LEVELS Table above.
 

1. QUARTERLY EXPOSURE OF INDIVIDUALS TO LESS THAN INVESTIGATIONAL LEVEL I.
 

Except when deemed appropriate by the RSO, no further action will be taken in those cases where an individual's exposure is less than values for Investigational Level I.
 

2. PERSONNEL EXPOSURE EQUAL TO OR GREATER THAN INVESTIGATIONAL LEVEL I, BUT LESS THAN INVESTIGATIONAL LEVEL II.
 

The RSO will review the exposure of each individual whose quarterly exposures equal or exceed Investigational Level I. He will report the results of his review at the first RSC meeting following the quarter when the exposure was recorded. If the exposure does not equal or exceed Investigational Level II, no action related specifically to the exposure is required unless deemed appropriate by the RSC. The RSC will, however, consider each exposure in comparison with those of others performing similar tasks as an index of ALARA program quality and will record the review in the RSC minutes. No written notification of the exposure will be forwarded to the individual.
 

3. PERSONNEL EXPOSURE GREATER THAN INVESTIGATIONAL LEVEL II.
 

The RSO will review techniques/procedures and make recommendations for reducing exposure. The RSC will review the recommendations and indicate appropriate follow-up. A written notification of the exposure will be forwarded to the individual.

C. ALARA REVIEW FORM
 

Name: SS No.:
 

Date:
 

This individual has exceeded the doses listed below.
 

ALARA Dose in mRem (mSv)/quarter
 

Level I Level II Dose Received

Whole body (Including Gonads, Lens

of Eyes, Red Bone Marrow) 125 (1.25) 375 (3.75)
 

Hands, Feet 375 (3.75) 1125 (11.25)
 

Skin of Whole Body 1250 (12.5) 3750 (37.5)
 

Reasons for excessive exposure:
 
 
 
 
 
 
 
 
 

Protective Considerations: Yes No N/A
 

1. Can time in the work area be reduced?
 

2. Will special dosimetry or area monitoring be required?
 

3. Can special tools/equipment be employed?
 

4. Can additional shielding/distance be employed?
 

Corrective action(s) taken:
 
 
 
 
 
 
 
 
 

Date Radiation Safety Officer
 
 
 

Acknowledgement
 

THIS REPORT IS FURNISHED TO YOU UNDER THE PROVISIONS OF THE LOUISIANA RADIATION PROTECTION REGULATIONS. YOU SHOULD RETAIN THIS REPORT FOR FURTHER REFERENCE.

II. RADIATION SAFETY COMMITTEE (RSC)
 

The control of radionuclides and radiation safety at Tulane University Medical Center is the responsibility of the RSC. Refer to Appendix A for a listing of the RSC members.
 

The RSC is responsible for:
 

a. Ensuring that all individuals who work with or in the vicinity of sources of radiation have sufficient training and work experience to enable them to perform their duties safely and in accordance with regulations and conditions of the license.
 

b. Ensuring that all use of sources of radiation is conducted in a safe manner and in accordance with regulations and conditions of the license.
 

The RSC shall:
 

a. Be familiar with all pertinent regulations, the terms of the license, and information in support of the request for the license and its amendments.
 

b. Review the training and experience of any individual who uses radioactive material (including physicians, technologists, physicists, and pharmacists) and determine that the qualifications are sufficient to enable them to perform their duties safely and in accordance with regulations and conditions of the license.
 

c. Establish a program to ensure that all individuals whose duties may require them to work in the vicinity of radioactive material (e.g., nursing, security and housekeeping personnel) are properly instructed.
 

d. Review and approve all requests for use of radioactive material within the institution.
 

e. Prescribe special conditions that will be required during a proposed use of radioactive material such as requirements for bioassays, physical examinations of users and special monitoring procedures.
 

f. Review the entire radiation safety program at least annually to determine that all activities are being conducted safely and in accordance with regulations and conditions of the license. The review shall include examination of all records, reports from the RSO, results of inspections, written safety procedures and management control systems.
 

g. Recommend remedial action to correct any deficiencies identified in the radiation safety program.
 

h. Maintain written records of all committee meetings, actions, recommendations and decisions. Minutes of the RSC meetings shall include: the date of the meeting, listing of the members present, listing of the members absent, a summary of the deliberations, a record of the recommended actions and the numerical results of any ballots.
 

i. Ensure that the radioactive material license is amended when necessary, prior to any changes in facilities, equipment, policies, procedures and personnel.
 

j. Include representatives from Nuclear Medicine, Radiology/Radiation Oncology, Nursing, Research and Management. The RSO shall also be a member of the RSC. A quorum of the RSC must include: the RSO, a representative from management and fifty percent (50%) of all RSC members.
 

The RSC shall meet as often as necessary to conduct its business, but not less than quarterly, or as often as the Joint Commission of Accreditation of Healthcare Organizations requires (JCAHO).
 

RSC members are listed in Appendix A.

III. RADIATION SAFETY OFFICER (RSO)
 

The RSO will be responsible for radiological safety. General surveillance over all activities involving radioactive material and determining compliance with rules and regulations, license conditions and conditions or projects as approved by the RSC are the responsibilities of the RSO.
 

The RSO is responsible for providing advice regarding procurement, safe handling, monitoring, use and disposal of all radioactive sources. He will furnish in-service education on all aspects of radiation protection to personnel at all levels of responsibility.
 

The RSO will maintain records of personnel exposure, and will notify individuals of exposures approaching maximum permissible amounts. An annual inventory of all radionuclides shall be maintained in order to assure the quantity on hand has been authorized by the license.
 

The RSO shall be notified in case of accidents and shall be responsible for the primary considerations involved in the prevention of spread of contamination. The RSO shall have one or more deputies.
 

The RSO will investigate all overexposures, accidents, losses, misadministrations or other excursions from good radiation safety. The maintenance of a procedure file on all matters relating to the radionuclide program from receipt to final disposition is the responsibility of the RSO. This also includes performance checks on survey equipment as well as in-service education. The RSO will review the radiation safety program in its entirety once per year.
 

The RSO is also responsible for the accuracy and completeness of other tasks required by regulation and will verify review by his signature on key documents. This does not mean that the RSO performs tasks, but rather that the record has been reviewed. Documents requiring the signature of the RSO:
 

A. Sealed source inventory.
 

B. Sealed source wipe/leak test.
 

C. Survey of sealed source storage areas.
 

D. Dose calibrator linearity.
 

E. Dose calibrator accuracy.
 

F. Dose calibrator geometry.
 

G. The RSO will:
 

1. Ensure that surveys shall be conducted in unrestricted areas.
 

2. Maintain records of radionuclide disposal by release to sewer which shall include (a) log of sewer disposal quantities by type of radionuclide (b) the daily effluent rate (c) monthly average concentration.
 

3. Maintain records of misadministrations of radionuclides and of the corrective actions taken.
 

4. Maintain records of semi-annual fume hood flow velocity calibrations.

IV. GUIDELINES FOR NUCLEAR MEDICINE ACTIVITIES INVOLVING TECHNICIANS AND OTHER PARAMEDICAL PERSONNEL.
 

A. An authorized physician may permit technologists and other paramedical personnel to perform the following activities:
 

1. Preparation and quality control testing of radiopharmaceutical sources of radiation.
 

2. Measurements of radiopharmaceutical doses prior to administration.
 

3. Use of appropriate instrumentation for the collection of data to be used by the physician.
 

4. Administration of radiopharmaceuticals from radionuclide sources to patients, within the limits permitted under applicable laws.
 

a. Whenever a technologist or other paramedical person administers a radiopharmaceutical to a patient by injection, a physician (not necessarily the authorized user of radionuclides) shall be immediately accessible.
 

B. Authorized physicians who permit activities to be performed by technologists and other paramedical personnel shall:
 

1. Prior to such permission, determine that such technologists and other paramedical personnel have been properly trained to perform their duties. This training shall include training in the following subjects as applicable to the duties assigned:
 

a. General characteristics of radiation and radioactive material.
 

b. Physical, chemical and pharmaceutical characteristics of each radiopharmaceutical to be used.
 

c. Mathematics and calculations basic in the use and measurement of radioactivity, including units of quantity of radioactivity (Curies, millicuries, microcuries, Becquerels) and units of radiation dose and radiation exposure (Roentgens, Rad, Rem, Gray and Sievert). See Appendix JJ.
 

d. Use of radiation instrumentation for measurements and monitoring, including operating procedures, calibration of instruments and limitation of instruments.
 

e. Principles and practices of radiation protection.
 

f. Additional training in the above subjects, as appropriate, when new duties are added.
 

2. Assure that such technologists and other paramedical personnel receive appropriate retraining in the subjects listed to maintain proficiency and to keep abreast of developments in the field of nuclear medicine.
 

3. Keep records showing the bases for such determinations of proper retraining.
 

4. Retain responsibility as authorized user for the satisfactory performance of such activities. Certification in Nuclear Medicine Technology by the American Registry of Radiologic Technology (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) will satisfy the above training requirements.
 

C. Personnel (Technologists and other paramedical) approved for radionuclide injections are listed in Appendix B.
 

V. ROUTINE FOR ORDERING, RECEIVING, OPENING PACKAGES CONTAINING RADIOACTIVE MATERIAL; PROCEDURE FOR DOCUMENTING USE OF MATERIAL
 

A. ORDERING
 

1. The Chief Technologist of the Nuclear Medicine Department will place all orders for radioactive material and will ensure that the requested materials and quantities are authorized by the Radioactive Material License (RMA). Possession limits are not to be exceeded.
 

2. A written record that identifies the radionuclide, chemical form and activity level shall be maintained.
 

3. A written request will be obtained from the physician who ordered the procedure. If a therapeutic procedure has been ordered, a written request will be obtained as well from the physician who will perform the procedure.
 

B. RECEIVING
 

1. During normal working hours, carriers will be instructed to deliver radioactive packages directly to the Nuclear Medicine Department.
 

2. During off-duty hours, security personnel or other designated individuals will accept delivery of radioactive packages in accordance with the procedures outlined in the sample memorandum, Section V.D.
 

C. MONITORING
 

Special requirements must be followed for packages containing quantities of radioactive material in excess of the Type A quantity limits, as defined in Radiation Regulations (e.g. more than 20 Curies of ⁹⁹Mo, ^99mTc, uncompressed ¹³³Xe or more than 3 Curies (3 Ci) of ¹³³Xe, ¹³¹I or ¹²⁵I. The licensee shall make arrangements to receive:
 

1. the package when the carrier offers it for delivery, or
 

2. the notification of the arrival of the package at the carrier's terminal and to take possession of the package expeditiously.
 

Such packages must be monitored for external radiation levels and surface contamination within three (3) hours after receipt if received during working hours or within eighteen (18) hours if received after working hours. The Division must be notified if removable contamination exceeds 0.01 µCi (22,000 dpm)/100 cm².
 

D. PROCEDURE FOR OPENING PACKAGES CONTAINING RADIOACTIVE MATERIAL
 

1. Put on impermeable disposable gloves to prevent hand contamination.
 

2. Visually inspect packages for any sign of damage (e.g. wetness, crushed). If damaged is noted, stop procedure and notify RSO.
 

Radiation Safety Officer: Charles F. Reindl, M.S.

Office: 584-2867

Home: 837-8516
 

Deputy Radiation Safety Officer: Michael T. Gauthier, B.S.

Office: 584-2878

Home: 738-2240
 

3. Measure the exposure rate from the package at one meter (1m) and at the package surface. If it is higher than expected, stop and notify the RSO. (The "transport index" noted on packages with "Yellow II" or "Yellow III labels is the approximate dose rate, in mR/hr at one meter (1m) from the package surface. The surface dose rate for such packages should not exceed 200 mR/hr. The dose rate from packages with "White I" labels should be less than 0.5 mR/hr at the package surface.
 

4. Open the package with the following precautionary steps:
 

1. Remove the packing slip.
 

2. Open the outer package following the suppliers' instructions, if provided.
 

3. Open the inner package and verify that the contents agree with the packing slip.
 

4. Check the integrity of the final source container. Look for broken seals or vials, loss of liquid, condensation or discoloration of the packing material.
 

5. If anything is other than expected, stop and notify the RSO.
 

5. If there is any reason to suspect contamination, wipe the external surface of the final source container and remove the wipe sample to a low-background area. Assay the wipe sample to determine if there is any removable radioactivity. The licensee should specify in the procedure manual which instrument (e.g. a thin-window G-M survey meter, a Sodium Iodide Thallium activated crystal and ratemeter, a liquid scintillation counter, or a proportional flow counter) should be used for these assays. The detection efficiency must be determined to convert wipe sample counts per minute (cpm) to disintegrations per minute (dpm). Note that a dose calibrator is not sufficiently sensitive for this measurement. Take precautions against the potential spread of contamination.
 

6. Check the user request to ensure that the material received is the material that was ordered.
 

7. Monitor the packing material and empty packages for contamination with a survey meter prior to discarding.
 

1. If contaminated, treat this material as radioactive waste.
 

2. If not contaminated, remove or obliterate the radation labels before discarding as in-house trash.
 

8. Record receipt of radioactive material on the proper form.
 

E. MEMO TO SECURITY
 

TO: Director of Security
 

FROM: Radiation Safety Officer
 

SUBJECT: RECEIPT OF PACKAGES CONTAINING RADIOACTIVE MATERIAL
 

Any packages containing radioactive material that arrive between 1630 hours and 0700 hours or during the weekend shall be accepted by the Security guard on duty and taken immediately to the Nuclear Medicine Department. Unlock the door, place the package on top of the counter and relock the door.
 

If the package is wet or appears to be damaged, immediately contact the Radiation Safety Officer. Ask the carrier to remain at the hospital until it can be determined that neither he/she nor the delivery vehicle is contaminated.
 

RADIATION SAFETY OFFICER: Charles F. Reindl, M.S.

Office: 584-2867
 

Home: 837-8516
 

NUCLEAR MEDICINE PHYSICIAN: Richard J. Campeau, M.D.

Office: 587-7567
 

Home: 866-6158
 

NUCLEAR MEDICINE TECHNOLOGIST: Verna Toups, R.T.

Office: 587-7567
 

F. PROCEDURES FOR DOCUMENTING USE OF RADIOACTIVE MATERIAL
 

1. A record of receipt, use, transfer, disposal and assay of all radioactive material shall be maintained for three (3) years.
 

2. See Appendices C-F for appropriate forms.

VI. INSTRUCTIONS FOR ADMINISTRATION OF RADIOPHARMACEUTICALS FOR DIAGNOSTIC AND THERAPEUTIC PROCEDURES
 

A. Before writing a prescription, the authorized user or physician under the supervision of an authorized user will personally review the patient's case to establish that the medical use is indicated for the patient.
 

B. Before administering a radiopharmaceutical, the authorized user or the physician under the supervision of an authorized user will personally make and date a prescription. If changes are required, they will be recorded in writing in the patient's chart or in another appropriate record, and will be dated and signed.
 

C. Before administering a radiopharmaceutical, the identity of the patient, the radiopharmaceutical, and the dosage will be confirmed by the person administering the radiopharmaceutical to establish agreement with the prescription. Any dose that differs from the prescribed dose by more than ten percent (10%) shall not be administered.
 

D. ASSAY OF RADIOPHARMACEUTICAL DOSAGES
 

1. Assay, within thirty (30) minutes before medical use, the activity of each radiopharmaceutical dosage that contains more than 10 µCi (370 kBq) of a photon-emitting radionuclide.
 

E. RECORD REQUIREMENTS
 

Retain a record of assays three (3) years. To satisfy this requirement, the record shall contain the following:
 

1. The patient's name and identification number (if one has been assigned).
 

2. The generic name or trade name, radiopharmaceutical abbreviation, lot number and expiration date of the radiopharmaceutical.
 

3. The prescribed dosage and activity of the dosage at the time of assay, or a notation that the total activity is less than 10 µCi (370 kBq).
 

4. The date and time of administration of the radiopharmaceutical.
 

5. The initials of the individual who performed the assay.
 

VII. LABORATORY RULES FOR USE OF RADIOACTIVE MATERIAL
 

A. Wear laboratory coats or other protective clothing at all times in areas where radioactive materials are used.
 

B. Wear impermeable disposable gloves at all times while handling radioactive material.
 

C. Monitor hands and clothing for contamination after each procedure or before leaving the area.
 

D. Use syringe shields for preparation of patient doses and administration to patients, except in circumstances (e.g. pediatric cases) where their use would compromise the patient's well-being.
 

E. Do not eat, drink, smoke or apply cosmetics in any area where radioactive material is being stored or used.
 

F. Do not pipette by mouth.
 

G. Assay each patient dose in dose calibrator prior to administration. Do not use any dose that differs from the prescribed dose by more than ten percent (10%). Check the patient's name and identification number and the prescribed radionuclide, chemical form and dosage prior to administration.
 

H. Wear personnel monitoring devices (film badge or thermoluminescent dosimeter [TLD]) at all times while in areas where radioactive materials are used or stored. These should be worn on the lapel. When not being worn to monitor occupational exposures, personnel monitoring devices should be stored in the work place in a designated low-background area.
 

I. Wear a ring badge when:
 

1. Eluting a generator
 

2. Preparing Kits (Radionuclide labeling)
 

3. Injecting mCi activities
 

4. When holding patients during procedures
 

J. Dispose of radioactive waste only in specifically designated, labeled and properly shielded receptacles.
 

K. Use plastic backed absorbent paper to cover the work area to absorb radioactive material in the event of a spill.
 

L. Confine the radioactive solutions in shielded containers that are clearly labeled. Radiopharmaceutical multidose diagnostic vials and therapy vials should be labeled with the isotope, the name of the compound, the date and time of receipt or preparation. A log book should be used to record the preceding information and total prepared activity, assay in mCi/cc at a specific time, total volume prepared, total volume remaining, the measured activity of each patient dosage and any other appropriate information. Syringes and unit dosages should be labeled with the radiopharmaceutical name or abbreviation, type of study or patient's name and identification number.
 

M. Always transport radioactive material in shielded containers.
 

N. Always keep flood sources, syringes, waste and other radioactive material in shielded containers.
 

O. Perform required Radiation Area and Contamination Surveys. See page XI-1.
 

P. The spread of contamination is a matter of good housekeeping.
 

1. Keep the laboratory neat and clean. Keep the work area free of equipment and material not required for the immediate procedure.
 

2. Wash hands and arms thoroughly before handling any object which goes to the mouth, nose or eyes. Monitor the hands whenever contamination is suspected and decontaminate immediately.
 

3. Keep fingernails short and clean. Do not work with radioactive material if there is a break in the skin below the wrist unless the wound is so protected that radioactive material cannot gain access to the body. Cover the break with an appropriate bandage (plastic or adhesive) and wear impermeable disposable gloves.
 

4. Food containers are not permitted in the laboratory. Refrigerators should not be used jointly for food and radioactive material storage.
 

Q. Radioactive Specimens, Excreta or Body Fluids
 

1. Excreta and Body Fluids may be disposed in the sanitary sewer.
 

2. Specimens shall be labelled with the radionculide, activity in µCi, date and special instructions to the pathologist.
 

3. All waste shall be disposed in accordance with Section XX of the RSM.
 

VIII. RESTRICTION AND LABELING OF RADIATION AREAS
 

A. All radiation areas are to be properly labeled and as such are to be restricted from entrance by unauthorized personnel.
 

B. A sign bearing the radiation caution symbol and the words "Caution High Radiation Area" will be posted when the level is such that a major portion of the body could receive in any one (1) hour a dose in excess of 100 mR (1 mSv).
 

C. A sign bearing the radiation caution symbol and the words "Caution Radiation Area" will be posted when the level is such that a major portion of the body could receive in any one (1) hour a dose in excess of 5 mR (0.05 mSv) or 100 mR/five (5) days.
 

D. A sign bearing the radiation caution symbol and the words "Caution Airborne Radioactivity Area" will be posted in any room, enclosure or operating area which has airborne radioactive materials in excess of the amounts specified in radiation regulations.
 

E. A sign bearing the radiation caution symbol and the words "Caution Radioactive Materials" will be displayed in all rooms and on containers in which radioactive material is stored or used.
 

F. "Notice to Employees will be posted in areas utilizing radioactive materials. See Appendix J.
 

IX. PERSONNEL MONITORING POLICY
 

A. REQUIREMENTS FOR MONITORING INDIVIDUALS
 

Personnel Monitoring is recommended for individuals for whom there is a reasonable probability of exceeding ten percent (10%) of the occupational dose equivalent limit of 5 rems/yr (50 mSv/yr) in the course of their work.
 

Personnel who work with radiation sources and may exceed ten percent (10%) of the occupational dose equivalent limit shall wear a personnel monitoring device (film badge or TLD) to assess actual exposure during work or as a check against unplanned exposures.
 

B. LOCATION OF PERSONNEL MONITORING DEVICE
 

All personnel monitoring devices are to be worn at the lapel. Whenever protective lead aprons are worn, the personnel monitoring devices shall be worn on the outside of the apron at the lapel.
 

For DECLARED PREGNANT WOMEN, a second personnel monitoring device shall be issued. The personnel monitoring device shall be worn at the waist under any protective apron in order to monitor embryo/fetal radiation dose.
 

C. RING BADGES
 

Any individual eluting a generator, preparing kits, injecting doses in the mCi or larger range or individuals performing invasive radiological procedures in which the hands of the individual could inadvertently become exposed to direct radiation shall be issued a ring badge for extremity (hand) monitoring.
 

D. EXCHANGE
 

Personnel monitoring devices and ring badges shall be exchanged at monthly intervals. All monitoring devices shall be returned no later than two (2) days after issue of new monitoring devices. New monitoring devices shall be worn within ±two (2) days of issue date.
 

E. ISSUE OF PERSONNEL MONITORING DEVICES; MAINTENANCE OF RECORDS
 

The RSO or Deputy RSO shall issue all personnel monitoring devices and (2) maintain results of monthly and annual dose summaries for all monitored individuals
 

F. THYROID MONITORING
 

Individuals involved in vented operations which utilize, at any one time, more than one millicurie (1 mCi) of ¹²⁵I and/or ¹³¹ or unvented laboratory operations involving 0.1 mCi of ¹²⁵I and/or ¹³¹I in an aqueous form shall have bioassays performed within 72 hours following a single operation and every two (2) weeks if use of these amounts continue. Records of the bioassay shall be maintained for inspection by the RSO and the action point listed below shall be observed.
 

INITIAL ACTION LEVEL: Greater than 0.12 µCi of 125I or 0.04 µCi of ¹³¹
 

IF INITIAL ACTION LEVEL IS EXCEEDED
 

a. An investigation of the operations involved, including air sampling surveys to determine the causes of exposure and to evaluate the potential for further exposures.
 

b. If investigation indicates, the licensee shall restrict the worker from further exposure until the source of exposure is discovered and corrected.
 

c. Corrective actions that will eliminate or lower the potential for further exposures shall be implemented.
 

d. A repeat bioassay shall be taken within two (2) weeks of the previous measurement in order to confirm the effectiveness of the corrective action taken and to obtain an estimate of effective half-life.
 

e. Reports or notification shall be provided as required by Radiation Regulations.
 

FINAL ACTION LEVEL: Greater than 0.5 µCi of ¹²⁵I or 0.14 µCi of ¹³¹I.
 

IF FINAL ACTION LEVEL IS EXCEEDED
 

a. Prevent the individual from any further handling of ¹²⁵ or ¹³¹I until the thyroid burden is below the limits.
 

b. As soon as possible, refer the case to appropriate medical consultant for recommendations regarding therapeutic procedures in order to accelerate removal of radioactive iodine from the body. This should be done within two to three (2-3) hours after exposure when the time of exposure is known so that any prescribed thyroid blocking agent would be effective.
 

c. Carry out repeated measurements at approximately one (1) week intervals until the thyroid is less than 0.12 µCi of ¹²⁵I or 0.04 µCi of ¹³¹I.
 

Individuals involved in administration of encapsulated ¹²⁵I and/or ¹³¹I shall not require thyroid monitoring unless the integrity of the capsule is broken. If this occurs, Section F.1 shall be observed.
 

X. LIMITS FOR EXPOSURE TO IONIZING RADIATION:
 

Summary of Recommendations^ab
 

A. Occupational exposures (annual)^c
 

1. Effective dose equivalent limit

(stochastic effects) 50 mSv (5 rem)
 

2. Dose equivalent limits for

tissues and organs (nonstochastic

effects)
 

a. Lens of eye 150 mSv (15 rem)
 

b. All others (e.g. red bone

marrow, breast, lung, gonads,

skin and extremities) 500 mSv (50 rem)
 

3. Guidance: Cumulative exposure 10 mSv x age (1 rem x age)
 

B. Planned special occupational exposure,

effective dose equivalent limit 100 mSv (10 rem)
 

C. Guidance for emergency occupational

exposure 100 mSv (10 rem)
 

D. Public exposures (annual)
 

1. Effective dose equivalent limit,

continuous or frequent exposure^c 1 mSv (0.1 rem)
 

2. Effective dose equivalent limit,

infrequent exposure^c 5 mSv (0.5 rem)
 

3. Remedial action recommended when:
 

a. Effective dose equivalentd >5 mSv (>0.5 rem)
 

b. Exposure to radon and its

decay products >0.007Jhm-3 (>2 WLM)
 

4. Dose equivalent limit for lens

of eye, skin and extremities 50 mSv (5 rem)
 

E. Education and training exposures (annual)^c
 

1. Effective dose equivalent limit 1 mSv (0.1 rem)
 

2. Dose equivalent limits for lens

of eye, skin and extremities 50 mSv (5 rem)
 

F. Declared Pregnant Females (Embryo-fetus exposures)
 

1. Total dose equivalent limit 5 mSv (0.5 rem)
 

2. Dose equivalent limit in a month 0.5 mSv (0.05 rem)
 

G. Negligible Individual Risk Level (annual)^c
 

1. Effective dose equivalent per source or

practice 0.01 mSv (0.001 rem)
 
 
 

^aExcluding medical exposures.
 

^bSee below for recommendations on Q.
 

^cSum of external and internal exposures.
 

^dIncluding background but excluding internal exposures.
 

RECOMMENDED VALUES OF Q FOR VARIOUS TYPES OF RADIATION
 

Type of radiation Approximate value of Q
 

X rays, rays, particles and electrons 1
 

Thermal neutrons 5
 

Neutrons (other than thermal), protons, alpha

particles and multiple-charged particles of unknown energy 20
 

XI. RADIATION AND CONTAMINATION AREA SURVEYS
 

A. All elution, preparation, and injection areas will be surveyed with a low range thin window G-M survey meter and decontaminated if necessary. NOTE: Each survey meter instrument shall be checked for proper operation with a dedicated check source before each use. Records of these checks are not required.
 

B. All areas where radionuclides are routinely prepared for use or administered shall be surveyed at the end of each day of use.
 

C. All areas where radionuclides are routinely prepared for use or administered including radionuclide storage locations shall be surveyed for removable contamination at the end of each week of use.
 

D. Measurement of radiation levels with the survey meter shall be sufficiently sensitive to detect 0.1 mR/hr.
 

The method for performing wipe tests will be sufficiently sensitive to detect 37 Bq/100 cm² (.001 µCi) for the contaminant involved.
 

E. A record will be kept of all survey results, including negative results. The record shall be maintained for three (3) years and will include:
 

1. Location, date and type of equipment used.
 

2. Name of person conducting the survey.
 

3. Drawing of area surveyed, identifying relevant features such as active storage areas, active waste areas, etc.
 

4. Measured exposure rates keyed to location on the drawing and at least one reading in an unrestricted area.
 

5. Detected contamination levels, keyed to locations on the drawing.
 

6. Corrective action taken in the case of contamination or excessive exposure rates, reduced contamination levels or exposure rates after corrective action, and any appropriate comments.
 

F. The area shall be considered contaminated if the ACTION LEVELS below are exceeded. The RSO shall be notified immediately if direct survey or contamination action levels are exceeded.
 

ACTION LEVEL Direct Survey: 2 X Bkg. @ Surface
 

ACTION LEVEL Removable Contamination: 37 Bq(0.001 µCi)
 

XII. DECONTAMINATION PROCEDURES
 

A. GENERAL CONSIDERATIONS
 

1. Prevent spread of contamination: The RSO should be called for assistance as soon as possible whenever a spill occurs. The first consideration shall include tracking by persons, movement by air currents (hoods, fans, etc.), water, mopping and other physical actions. To confine it, decontaminate spill from outside toward center.
 

2. Make a plan: Successful decontamination calls for planned action. A spur of the moment action or attempt at decontamination can cause more harm than good. The best thing to do after a spill is make a thorough plan of the steps to be taken in the decontamination procedure.
 

3. Monitoring: Make full use of instruments and available assistance. Each step of the decontamination should be monitored. One person should be kept clean to operate instruments and do other monitoring. When instruments become contaminated, any progress is hopeless. Protective clothing, footwear, gloves and assault masks should be used as needed.
 

4. Records: Complete records should be made of each action. Copies should be sent to the RSO. In most cases, the RSO will be involved in the clean-up, thus a joint report can be filed.
 

5. Waste disposal: Provisions must be made for disposal of cleaning solutions and contaminated articles. In some instances, it may be judged better to dispose of a contaminated article rather than to attempt to decontaminate.
 

B. SPECIFIC PROCEDURES
 

1. Skin and hands as contaminated areas.
 

a. Decontaminating agent - mild soap and water or detergent and water. If necessary, follow by soft brush, heavy lather and tepid water.
 

b. Remarks - Wash two to three (2 - 3) minutes and monitor. Do not wash over three (3) or four (4) times. Use light pressure with heavy lather. Wash for two (2) minutes, three times. Rinse and monitor. Use care not to scratch or erode skin.
 

c. Maximum permissible levels of contamination:
 

Alpha - 150 dpm/100 cm²
 

Beta-Gamma - Average less than 0.3 mR/hr for each hand surface or 100 cm² of skin surface, using GM survey meter.
 

2. Wounds (cuts and breaks in skin)
 

a. Decontaminating agent - running tap water. Report to physician and RSO.
 

b. Remarks - wash wound with large volumes of running water. Spread wound to permit flushing action by water.
 

c. Maximum permissible levels of contamination - keep wound contamination as low as possible.
 

3. Ingestion by swallowing
 

a. Decontaminating agent - immediately induce vomiting. Drink large quantities of liquids to dilute activity.
 

b. Remarks - urine and feces analysis will be necessary to determine amount of radionuclides in body.
 

XIII. CONTAMINATED EQUIPMENT
 

A. Radioactive contamination is defined as the deposition of radioactive material in any place where it is not desired and particularly in any place where its presence may be harmful. Under no circumstances shall contaminated equipment be in the laboratory or be returned to a stock room.
 

B. Equipment that may be reused should be decontaminated.
 

C. Contaminated equipment which is no longer of any use may be discarded in the dry active waste can. If too large for such disposal, request a survey and disposal information from the RSO.
 

D. Equipment to be repaired by shop and maintenance personnel or by a commercial contractor shall be demonstrated to be free of contamination prior to servicing.
 

E. If it becomes necessary to make emergency repairs on contaminated equipment, the work will be supervised by the RSO who will assure that the necessary safeguards are taken. It is the responsibility of the laboratory personnel to request this supervision.
 

XIV. EMERGENCY PROCEDURES
 

A. WHOM TO CALL
 

In the event of an emergency, i.e., spills, bodily injury and contamination involving a radiation source, fires, etc., notify the RSO.
 

RSO: Charles F. Reindl, M.S.

Office: 584-2867

Home: 837-8516
 

Deputy RSO: Michael T. Gauthier, B.S.

Office: 584-2878

Home: 738-2240
 

In addition, each particular lab should have posted the location of the nearest fire alarm and the phone number of the Fire Department.
 

B. LOSS OF SOURCE
 

Immediately upon discovery of a loss of a sealed source, an appropriate plan of action should be initiated. An example of such a plan would be as follows:
 

1. Call the RSO immediately.
 

2. Make a list of all possible places in which the source might have been and where it might be found.
 

3. Choose the most sensitive and appropriate portable survey instruments (e.g. mR meters or portable scintillation detectors for gamma or high energy beta emitters) for conducting the search.
 

4. If the source had been transported, check the entire route of travel;
 

5. If the source had been used with a patient, survey the patient, the patient's room and all bandages, linen, bedding and trash from the patient's room.
 

6. Survey the entire route from the patients room to the laundry and the laundry facility.
 

7. Survey the entire route from the patient's room to the incinerator, the incinerator, trash awaiting incineration and the incinerator ash.
 

8. Survey the entire route from the patient's room to the dumpster and the trash in the dumpster. If needed, request Security to impound the dumpster until the search can be completed.
 

9. If instruments had been used with the patient, survey the entire route from the patient's room to the instrument cleaning and sterilization areas.
 

10. Survey all areas where the source might be found, such as sink drains or plumbing fixtures, elevator shafts, waste cans, trash bins and vacuum cleaners or house vacuum systems.
 

11. Continue the search until the source is found or the search is terminated by the RSO.
 

12. The RSO shall notify the Radiation Protection Division.
 

C. STORAGE IN ANTICIPATION OF NATURAL CATASTROPHY
 

In the event of hurricane, flooding or other disaster, all radioactive material should be returned to the storage site. Individual amounts of material should be stored in double containers and sealed as well as possible to prevent leakage. Each container should be labeled with the name of the radionuclide, its chemical form and activity present on a specified date. The storage safe or cabinet should be locked and sealed with waterproof tape. If time permits, a list of the radionuclides placed in the storage area should be posted with the date and activity present. If a suitable storage area does not exist, contact the RSO.
 

D. MINOR SPILLS
 

1. NOTIFY: All persons in the area that a spill has occurred.
 

2. PREVENT THE SPREAD: Cover the spill with absorbent paper.
 

3. CLEAN UP: Use disposable gloves and remote handling tongs. Carefully fold the absorbent paper and pad. Insert into a plastic bag and dispose of in the radioactive waste container. Include all other contaminated materials such as impermeable disposable gloves.
 

4. SURVEY: With a G-M survey meter, check the area around the spill, hands, clothing and shoes for contamination.
 

5. REPORT: Report incident to the RSO.
 

E. MAJOR SPILLS
 

1. CLEAR THE AREA: Notify all persons not involved in the spill to vacate the room.
 

2. PREVENT THE SPREAD: Cover the spill with absorbent pads; do not attempt to clean. Confine the movement of all personnel potentially contaminated to prevent the spread.
 

3. SHIELD THE SOURCE: If possible, the spill should be shielded, but only if it can be done without further contamination or increased radiation exposure.
 

4. VENTILATION SYSTEM: Switch off all fans and air conditioners.
 

5. CLOSE THE ROOM: Leave the room and lock the door(s) to prevent entry.
 

6. CALL FOR HELP: Notify the RSO immediately.
 

7. PERSONNEL DECONTAMINATION: Contaminated clothing should be removed and stored for further evaluation by the RSO. If the spill is on the skin, flush thoroughly and wash with mild soap and tepid water.
 

F. ACCIDENT INVOLVING RADIOACTIVE DUSTS, MISTS, FUMES, ORGANIC VAPORS AND GASES
 

1. NOTIFY all other persons to vacate the room immediately.
 

2. HOLD BREATH and close return air vents, switch off air circulating devices, etc., if time permits.
 

3. VACATE the room.
 

4. NOTIFY the RSO.
 

5. Ascertain that all DOORS GIVING ACCESS TO THE ROOM ARE CLOSED and post conspicuous warnings or guards to prevent accidental opening of doors.
 

6. REPORT at once all known or suspected inhalations of radioactive material.
 

G. INJURIES TO PERSONNEL INVOLVING RADIATION HAZARD
 

1. WASH MINOR WOUNDS immediately under running water while spreading the edges of the wound.
 

2. REPORT all radiation accidents involving personnel (wounds, overexposures, ingestion, inhalation) to the RSO.
 

3. CALL A PHYSICIAN qualified to treat radiation injuries.
 

4. Permit no person involved in a radiation injury to return to work without approval of the RSOfficer and attending physician.
 

H. FIRES
 

1. FOLLOW "FIRE" PROCEDURE in Emergency Preparedness Manual.
 

2. NOTIFY the RSO.
 

3. GOVERN THE FIRE-FIGHTING OR OTHER EMERGENCY EQUIPMENT observing restrictions of the RSO.
 

4. Following the emergency, monitor the area and determine the protective devices necessary for safe decontamination.
 

5. Decontamination shall be supervised by the RSO.
 

XV. INSTRUCTION FOR MAINTENANCE
 

A. Maintenance personnel should enter the laboratories employing radioactive sources only for authorized and necessary purposes.
 

B. When radioactive sources are properly stored, it is not dangerous to enter these areas. If in doubt concerning hazards present, contact the RSO.
 

C. General maintenance work may be performed only when all radioactive materials have been returned to their shielded containers. Contact the technologist before initiation of cleaning or general maintenance work.
 

D. If sign below is posted, entry is prohibited.
 

E. Maintenance personnel shall notify the RSO before any alterations to shielding or to shielded areas.
 

XVI. INSTRUCTIONS FOR HOUSEKEEPING
 

Radiation, as we know it today, is found in many forms and amounts. Radiation has always been present to some degree in nature, our food, building materials and our bodies. Even though levels of radioactivity in most areas are very low, personnel should use caution and have respect for the possible hazard. As part of this caution:
 

A. DO observe warning signs.
 

B. DO report to your supervisor anything you think is not right.
 

C. DO NOT empty waste cans labeled with the radiation sign.
 

D. DO NOT dispose of any packages or other containers labeled with an undefiled radiation sign. If you are in doubt, contact your supervisor.
 

E. DO NOT clean any spills, either wet or dry, in areas that use radioactive material, until you have been assured that the spill is not radioactive.
 

F. DO NOT handle or move containers with the radiation sign.
 

G. DO contact the RSO if you have any questions or concerns.
 

XVII. ESCORT PERSONNEL
 

Prior to transporting a patient with an implanted radioactive source, the escort should be informed of the location of the implanted source. The escort should be given a personnel monitoring device to wear and should be instructed on its use. Escort personnel should observe the following:
 

A. Minimize their exposure by staying as far from the source as is possible while transporting the patient (unless otherwise advised by the RSO or the medical staff individual assisting the patient).
 

B. Use designated patient elevators.
 

C. If public elevators are used, the general public should be excluded.
 

D. The least crowded corridors should be selected for passage.

XVIII. INSTRUCTIONS FOR VISITORS
 

A. No visitors are permitted in any laboratory using a radiation source unless accompanied by a qualified individual familiar with the hazards involved.
 

B. All visitors shall be issued a personal monitoring device when they enter an area in which radioactive materials are located in such amounts that they constitute a potential personal hazard or increase the possibility of spread of contamination. Accumulated doses shall be recorded for the visitor along with the individual's name, age and address. This information shall be sent in a written memorandum to the RSO to be kept on file.
 

C. Pregnant female visitors shall not be permitted in laboratories using a radiation source.
 

XIX. STORAGE OF RADIONUCLIDES
 

All areas where radioactive materials are used and stored shall be locked when not attended by authorized personnel.
 

A. LIQUIDS AND SOLIDS
 

1. All radioactive samples must be clearly labeled at all times with pertinent information about the contents, such as the name of the isotope, its chemical form and the quantity of radioactive material as well as the name of the responsible individual.
 

2. Storage sites for large amounts of radioactive material should be as remote from occupied areas as is practical.
 

3. The background radiation in unrestricted areas shall be such that individuals continuously present in the area will not receive a dose in excess of 2 mR in any one hour or will not receive a dose in excess of 100 mR in any seven (7) consecutive days. The whole body exposure in unrestricted areas shall be such that any individual will not receive a dose in excess of 0.5 rem in any period of one (1) calendar year.
 

4. The storage place should be chosen as to minimize risk from fire. The storage place should have a suitable means of egress.
 

5. The storage areas shall be well marked with a "Caution Radioactive Materials" sign. If necessary, entrance requirements shall be posted.
 

B. GASES
 

1. The general storage requirements listed above apply as well as the following considerations:
 

a. Radioactive solutions that emit gases shall be labeled and kept in approved hoods which are provided with filters and have adequate ventilation.
 

b. In general, only such amounts of material as are necessary for immediate experiments or diagnostic exams should be stored in the laboratory area.
 

c. For maximum permissible concentrations in air, consult the RSO.
 

XX. RADIONUCLIDE DISPOSAL
 

The following general guideline and procedure may be used for disposal of radioactive waste.
 

There are four (4) commonly used methods of waste disposal: (1) release to the environment through the sanitary sewer or by evaporative release (2) decay-in-storage (DIS) (3) transfer to a burial site or back to the manufacturer and (4) release to in-house waste. With the exception of patient excreta and generally licensed in vitro kit exemptions, nothing in these guidelines relieves the licensee from maintaining records of the disposal of licensed material.
 

A. GENERAL GUIDANCE
 

1. Follow "UNIVERSAL PRECAUTIONS" while handling all waste.
 

2. Records of all amounts in µCi of all radionuclides must be maintained.
 

3. All radioactivity labels must be defaced or removed from containers and packages prior to in-house waste disposal. If waste is compacted, all labels that are visible in the compacted mass must be defaced or removed.
 

4. Remind employees that nonradioactive waste such as leftover reagents, boxes and packaging material should not be mixed with radioactive waste.
 

5. Occasionally monitor all procedures to ensure that radioactive waste is not created unnecessarily. Review all new procedures to ensure that waste is handled in a manner consistent with established policies.
 

6. In all cases, consider the entire impact of various available disposal routes. Consider occupational and public exposure to radiation, other hazards associated with the material and routes of disposal (e.g, toxicity, carcinogenicity, pathogenicity, flammability and expense).
 

B. PROCEDURE FOR DISPOSAL OF LIQUIDS AND GASES
 

Liquids may be disposed of by release to the sanitary sewer or evaporative release to the atmosphere. This does not relieve licensees from complying with other regulations regarding toxic or hazardous properties of these materials.
 

1. Material must be readily water soluble or readily dispersible biological material in water. There are monthly limits based on the total sanitary sewerage release of your facility. (Excreta from patients undergoing medical diagnosis or therapy is exempt from all the above limitations). Make a record of the date, radionuclide and estimated activity that was release in µCi of mCi and of the sink or toilet at which the material was released.
 

2. Limits on permissible concentrations in effluents to unrestricted areas are enumerated in the regulations. These limits apply at the boundary of the restricted area. Make a record of the date, radionuclide, estimated activity that was released in µCi or mCi and of the vent site at which the material was released.
 

C. PROCEDURE FOR DISPOSAL BY DECAY-IN-STORAGE (DIS)
 

Short-lived material (physical half-life less than 65 days) may be disposed of by DIS. If you use this procedure, keep material separated according to half-life.
 

1. Use separate containers for different types of waste, e.g., capped needles and syringes in one container, other injection paraphernalia such as swabs and gauze in another, and unused dosages in a third container. Smaller departments may find it easier to use just one container for all DIS waste. Because the waste will be surveyed with all shielding removed, the containers in which waste will be disposed of must not provide any radiation shielding for material.
 

2. When the container is full, seal it with tape and attach an identification tag that includes the date sealed, the longest-lived radioisotope in the container and the initials of the individual sealing the container. The container may then be transferred to the DIS area.
 

3. Decay the material for at least ten (10) half-lives.
 

4. Prior to disposal as in-house waste, monitor each container as follows:
 

a. Check your radiation detection survey meter for proper operation.
 

b. Plan to monitor in a low-level (<0.05 mR/hr) area.
 

c. Remove any shielding from around the container.
 

d. Monitor all surfaces of each individual container.
 

e. Discard as in-house waste only those containers that cannot be distinguished from bkg. Record the date on which the container was sealed, the disposal date and type of material (e.g., paraphernalia, unused dosages). Check to be sure no radiation labels are visible.
 

f. Containers that can be distinguished from background radiation levels must be returned to the storage area for further decay or transferred for other disposal.
 

5. If possible, 99Mo/99mTc generators should be held 60 days before being dismantled due to the occasional presence of a long-lived contaminant. When dismantling generators, keep a radiation detection survey meter (preferable with a speaker) at the work area. Dismantle the oldest generator first, then work forward chronologically. Hold each individual column in contact with the radiation detection survey meter in a low-background (<0.05 mR/hr) area. Log the generator date and disposal date for your waste disposal records. Remove or deface the radiation labels on the generator shield.
 

D. PROCEDURE FOR TRANSFER FOR BURIAL
 

Except for material suitable for DIS and some animal carcasses, solids must be transferred to a burial site. Follow the packaging instructions you received from the transfer agent and the burial site operator. For your records of disposal, keep the consignment sheet that the transfer agent remitted to you.
 

E. PROCEDURE FOR RETURNING GENERATORS TO THE MANUFACTURER
 

Used 99Mo/99mTc generators may be returned to the manufacturer. This permission dose not relieve the licensee from the requirement to comply with Department of Transportation (DOT) regulations.
 

1. Retain the records needed to demonstrate that the package qualifies per DOT regulations.
 

2. Assemble the package in accordance with the manufacturer's instructions.
 

3. Perform the dose rate and removable contamination measurements.
 

4. Label the package and complete the shipping papers in accordance with the manufacturer's instructions.
 

F. TRANSFER TO UNIT DOSE PHARMACY OR COMMERCIAL DISPOSAL AGENCY
 

1. Only unused doses, oral therapy doses and containers and bulk ^99mTc may be returned to the pharmacy.
 

2. Brachytherapy sources may be transferred to supplier provided DOT regulations are satisfied.
 

3. Records shall be maintained of amounts of radioactive materials transferred to commercial disposal agency licensed to receive radioactive waste materials.
 

G. SPECIFIC WASTES
 

1. BACTEC ¹⁴C TEST VIALS
 

a. Autoclave all vials to destroy pathogens.
 

b. Liquids may be disposed via sanitary sewer system. On no single day will more than 1 mCi be released in the sewer system. Over a period of one (1) month, the activity released, when diluted by the average monthly quantity of water, will not exceed a concentration of 3X10^-4 µCi/ml of ¹⁴C.
 

c. After autoclaving and rinse, the vials shall be placed in plastic bags for disposal with other laboratory waste material.
 

d. Care should be exercised to protect vials from breakage during autoclaving and rinsing procedures.
 

e. Vials may alternatively be incinerated.
 

2. ³H, ¹⁴C
 

a. 0.05 µCi or less of the above radioactive material/g of medium used for scintillation counting may be disposed without regard to radioactivity providing that all regulations governing any other toxic or hazardous property of these materials are observed.
 

H. INFECTIOUS, HIGHLY TOXIC, HAZARDOUS SUBSTANCES
 

a. Plans for proper disposal of infectious agents, highly toxic and/or hazardous substances shall be made early in the design stage of an experiment. Proposed procedures involving unusual problems will be considered individually by the RSC.
 

I. INCINERATION
 

Radioactive waste is accepted in Room 1105 of the Medical School, Tuesday and Thursday from 8:30 to 10:30 a.m.
 

In order to ensure that air activity limits for unrestricted areas are not exceeded, limits on activity incinerated per hour are imposed based on the following equation: 2858 cfm X 60 min/hr X 28,320 ml/cubic foot = 4.85 X 10⁹ ml/hr. For example, the maximum concentration of H-3 in unrestricted air = 1 X 10^-7 µCi/ml; 1 X 10^-7 µCi/ml X 4.85 X 10⁹ ml/hr = 485 µCi/hr; other radionuclides are limited by use of the same equation: maximum concentration X 4.85 X 10⁹ ml/hr = allowable burn/hr.
 

A sample of the resulting ash from the ash bin must be collected and analyzed for the radionuclide(s) burned. The ash must not be released until it is at or below the effluent concentration limit for water. Ash may be held until a decay calculation yields an activity concentration at or below this limit. If this is not possible, the ash must be packaged for disposal as radioactive waste.
 

The activity amount of each radionuclide burned must be totalled and divided by the total activity amount allowed to be burned during that time period. This fraction is equivalent to Concentration in Air/Maximum Allowable Concentration. The fraction for each isotope must be totalled and recorded. Although unity may be exceeded during some weeks, the average for the year shall not exceed unity.
 

XXI. SAFETY RULES: FIXED RADIOGRAPHIC
 

A. Particular care should be taken to limit the useful beam to the smallest area consistent with clinical requirements and to align accurately the X-ray beam with the patient and film.
 

B. Gonadal shielding should be used for the patient when appropriate, but never as a substitute for adequate beam collimation and alignment.
 

C. When a patient must be held in position for radiography, mechanical supporting or restraining devices should be used. If the patient must be held by an individual, that individual shall be protected with appropriate shielding devices, such as protective gloves and apron. The individual should be so positioned that no part of his body will be struck by the useful beam and that his body is as far as possible from the edge of the useful beam.
 

D. Special precautions, consistent with clinical needs, should be taken to minimize exposures of the embryo or fetus in patients known to be or suspected of being pregnant.
 

E. Use the maximum source-skin distance consistent with the conditions of the examination.
 

F. Only persons whose presence is necessary shall be in the radiographic room during exposure. All such persons shall be protected.
 

G. The radiographer shall stand behind the barrier provided for his/her protection during radiographic exposures.
 

H. Special care shall be taken to insure adequate filtration in multi-purpose machines. Particular care shall be taken to insure adequate filtration in any machine equipped with a beryllium window tube.
 

XXII. SAFETY RULES: FIXED FLUOROSCOPIC
 

A. Particular care should be taken to limit the useful beam to the smallest area consistent with clinical requirements and to align accurately the X-ray beam with the patient and film.
 

B. Gonadal shielding should be used for the patient when appropriate, but never as a substitute for adequate beam collimation and alignment.
 

C. When a patient must be held in position for radiography, mechanical supporting or resteraining devices should be used. If the patient must be held by a individual, that individual shall be protected with appropriate shielding devices, such as protective lead gloves and an apron. The individual should be so positioned that no part of his body will be struck by the useful beam and that his body is as far a possible from the edge of the useful beam.
 

D. Special precautions, consistent with clinical needs, shold be taken to minimize exposures of the embryo or fetus in patients know to be or suspected of being pregnant.
 

E. Use the maximum source-skin distance consistent with the conditions of the examination.
 

F. Protective aprons of at least 0.5 mm lead equivalent should be worn in the fluoroscopy room by each person (except the patient). X-ray monitoring devices shall be worn by all persons in the X-ray room (except the patient) on the outside of the protective apron on the lapel.
 

G. Only persons whose presence is required shold be in the fluoroscopic room.
 

H. The hand of the fluoroscopist shold not be placed in the useful beam unless the beam is attenuated by the patient and a protective glove of at least 0.5 mm lead equivalent.
 

I. Fluoroscopy should not be utilized as a substitute for radiography. Fluoroscopy is to be reserved for the study of dynamics, special relationships or guidance in spot filming of critical details.
 

J. In cineradiography, special care must be taken to limit patient exposure when, as is often the case, tube currents and potentials employed are higher than those normally used in fluoroscopy.
 

K. Image intensification shall always be provided on mobile fluoroscopic equipment. It shall be impossible to operate mobile fluoroscopic equipment unless the useful beam is intercepted by the image intensifier.
 

XXIII. SAFETY RULES: OPERATORS OF MOBILE RADIOGRAPHIC EQUIPMENT
 

A. Particular care should be taken to limit the useful beam to the smallest area consistent with clinical requirements and to align accurately the X-ray beam with the patient and film.
 

B. Gonadal shielding should be used for the patient when appropriate, but never as a substitute for adequate beam collimation and alignment.
 

C. When a patient must be held in position for radiography, mechanical suppoorting or restraining devices should be used. If the patient must be held by an individual, that individual shall be protected with appropriate shielding divices, such as protective lead gloves and an apron. The individual should be so positioned that no part of his body will be struck by the useful beam and that his body is as far as possible from the edge of the useful beam.
 

D. Special precautions, consistent with clinical needs, should be taken to minimize exposures of the embryo or fetus in patients known to be or suspected of being pregnant.
 

E. Use the maximum source-skin distance consistent with the conditions of the examination.
 

F. Mobile X-ray equipment shall not be used for fluoroscopy, unless it meets the requirements for mobile fluoroscopes.
 

G. Mobile equipment should be used only for examinations where it is impractical to transfer patients to permanent radiographic installations.
 

H. Patients in adjoining beds should be at least twelve (12) feet away from the central ray of the primary beam. If the beds cannot be moved, adjacent patients shall be furnished with a 0.5 mm lead equivalent apron.
 

I. Prior to making the X-ray exposure, the technologist will announce his/her intention to do so. No exposure is to be made if any person, other than the patient is within a twelve (12) foot radius of the X-ray beam and is not properly shielded.
 

XXIV. SAFETY RULES: OPERATORS OF MOBILE FLUOROSCOPIC EQUIPMENT
 

A. Particular care should be taken to limit the useful beam to the smallest area consistent with clinical requirements and to align accurately the X-ray beam with the patient and film.
 

B. Gonadal shielding should be used for the patient when appropriate, but never as a substitute for adequate beam collimation and alignment.
 

C. When a patient must be held in position for radiography, mechanical supporting or restraining devices should be used. If the patient must be held by an individual, that individual shall be protected with appropriate shielding devices, such as protective lean gloves and an apron. The individual should be so positioned that no part of his body will be struck by the useful beam and that his body is as far as possible from the edge of the useful beam.
 

D. Special precautions, consistent with clinical needs, should be taken to minimize exposures of the embry or fetus in patients known to be or suspected of being pregnant.
 

E. Use the maximum source-skin distance consistent with the conditions of the examination.
 

F. Stand as far as possible from the patient, the tube and the useful beam.. Wear a protective apron or stand behind a suitable shield of at least 0.5 mm lead equivalent.
 

XXV. SAFETY RULES: PERSONS IN THE VICINITY OF MOBILE X-RAY EQUIPMENT
 

A. Vacate the room if possible.
 

B. If in the room, stand as far as possible from the patient, the X-ray tube and the useful beam.
 

C. Declared pregnant women shall not hold patients.
 

D. Follow all instructions given by the X-ray technologist.
 

C. When a patient must be held in position for radiography, mechanical supporting or restraining devices should be used. If the patient must be held by an individual, that individual shall be protected with appropriate shielding devices, such as protective lead gloves and an apron. The individual should be so positioned that no part of his body will be struck by the useful beam and that his body is as far as possible from the edge of the useful beam.
 

XXVI. SPECIFIC INSTRUCTIONS FOR ALLIED MEDICAL WORKERS
 

Housekeeping Personnel:
 

All housekeeping personnel should be aware of the locations of all restricted area in order to practice good radiation protection measures.
 

The measures are:
 

1) Get user permission and instructions from the RSO before cleaning any spill in restricted area.
 

2) Do not clean counter tops, hoods, refrigerators or sinks in restricted areas unless specifically reques