SY14 Use of Radioactive Materials

Contents:

• Purpose
• Reference
• Definitions
• Applicability
• Policy
• Responsibilities
  • Senior Vice President for Research
  • Department of Environmental Health and Safety
  • Radiation Safety Officer
  • University Isotopes Committee
  • Office for Research Protections
  • Principal Investigators (Supervisors)
  • Individual Users
• Training
• Acquisition, Storage, Transfer, and Disposal of Radioactive Material
• Use of Radioactive Material
• Emergencies
• Further Information
• Cross References

PURPOSE:

This document establishes policy and procedures for the acquisition, use, storage, and disposal of radioactive material at all Penn State locations except for the Hershey Medical Center, and the College of Medicine.

REFERENCE:

The ownership and use of a radioactive material is governed by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (DEP) and the United States Nuclear Regulatory Commission (NRC). DEP requirements can be found in Title 25 of the Pennsylvania Code Article V.Radiological Health, and NRC requirements can be found in applicable parts of Title 10, Code of Federal Regulations. Regulations of the U. S. Departments of Transportation, the Food and Drug Administration, and the Environmental Protection Agency also apply.

Penn State's University Isotopes Committee (UIC) has approved the Rules and Procedures for Users of Radioactive Material at the Pennsylvania State University. These Rules and Procedures are available by contacting the Department of Environmental Health and Safety (EHS) or at the EHS website.

DEFINITIONS:

Radioactive material as used in this policy includes:

Specifically licensed material: Radioactive material that may be used by a specific legal entity for a specific purpose. The Nuclear Regulatory Commission and the Commonwealth of Pennsylvania grant the University permission to use this material. This permission comes with many very specific restrictions. Examples of this material include all radioactive material used in molecular biology labs, gauges, irradiators and the material produced at the Breazeale Nuclear Reactor. At Penn State, natural uranium and thorium compounds (acetates, nitrates, and oxides) are included in this category.

Generally licensed material: Radioactive material contained in a device manufactured for a particular purpose. General licenses are issued (in effect) to Penn State when an item containing radioactive material is sold to Penn State. These licenses have fewer, but still important, restrictions. Examples of this material include certain specific devices such as some gas chromatographs, self-luminescent exit signs, and liquid scintillation counters.

License exempt material: Radioactive materials considered too small to be hazardous -- as long as the material is used as intended. Examples of this material include low activity check sources, standards for radiation detection equipment, smoke detectors, natural radioactive materials in ceramics, and natural ores and minerals below specific uranium and thorium concentrations.

APPLICABILITY:

This policy applies to possession and use of all radioactive material at all Penn State University locations except the Hershey Medical Center, the College of Medicine and the radioactive material produced at the Breazeale Nuclear Reactor and retained under the control of that specific reactor license.

POLICY:

It is the policy of Penn State University that the release of radioactive material and the exposure of people to ionizing radiation be kept As Low As Reasonably Achievable (ALARA). To achieve this goal, all users of radioactive material shall comply with the Rules and Procedures for Users of Radioactive Material at The Pennsylvania State University. Penn State's University Isotopes Committee established these rules to aid compliance with federal and state regulations.

All supervisors of laboratories that will use specifically licensed radioactive material are required to obtain approval from the UIC prior to obtaining the material.  The application may be acquired by contacting Environmental Health and Safety or at the EHS website.

RESPONSIBILITIES:

Senior Vice President for Research

The Senior Vice President for Research is the senior University official responsible to the Nuclear Regulatory Commission and the Commonwealth of Pennsylvania for compliance with specific radioactive material licenses issued to the University. The Senior Vice President for Research appoints the University Isotope Committee to perform those functions required of the licenses, and delegates to the UIC the authority and responsibility to review all requests for the use of radioactive materials, and to approve, deny, or revoke such authorizations

Department of Environmental Health and Safety

The office of Environmental Health and Safety administers the University's health and safety programs and is responsible for implementing the radiation safety program to ensure protection of people and the environment, as well as regulatory compliance. EHS assists users of radioactive material in developing safe research programs and procedures, maintains surveillance of all activities involving licensed radioactive material, and enforces compliance with rules and regulations, license conditions, and the conditions of project approvals authorized by the University Isotopes Committee.

In addition, EHS is responsible to:

• Oversee the receipt and shipment of all radioactive material arriving at or leaving the University
• Instruct personnel in radiation safety prior to their use of radioactive material
• Manage the proper disposal of radioactive waste
• Maintain the inventory of specifically licensed radioactive material
• Track and control the use of generally licensed radioactive material

Radiation Safety Officer

The Radiation Safety Officer (RSO), as a member of EHS, is responsible for assuring that all radioactive materials at Penn State locations are used in accordance with good health physics practices, applicable regulations, and this policy. The RSO has the duty to interrupt and report to the UIC any isotope operation in which health and safety may be compromised and any operation that may result in non-compliance with University regulations. The RSO is responsible for performing those duties required by federal and state regulations.

University Isotopes Committee

The University Isotopes Committee is responsible for the administration of specific licenses issued to the University for the use of radioactive materials and insuring that such licensed use meets federal, state,and University regulations. In addition the UIC evaluates procedures, and approves, denies, or rescinds, individual University isotope authorizations. The Committee meets on a quarterly basis to address the University's radioactive material status.

Office for Research Protections

The Office for Research Protections facilitates the review process for research protocols involving the use of radioisotopes. It is responsible for administrating the activities of the University Isotope Committee with emphasis on implementation of committee decisions, enforcement of UIC sanctions, and the coordination of protocol reviews. The office also monitors UIC membership and maintains complete and accurate records of UIC activities.

Principal Investigators (Supervisors)

Principal investigators are required to obtain prior approval from the University Isotopes Committee for authorization to use specifically licensed radioactive material. Each supervisor is responsible for all activities involving radioactive material under his or her jurisdiction. The supervisor is responsible for properly training his or her staff in accordance with this policy, and for ensuring compliance with this policy and the terms of the authorization approved by the UIC. In addition, all Principal Investigators authorized to possess radioactive material are responsible to pay Pennsylvania Department of Environmental Protection license fees for the use of radioactive materials. Procedures for payment are established through EHS.

To obtain approval from the UIC, the principal investigator must submit the Request for Authorization to Use Radioactive Material, which is available at the EHS web site. No one may supervise the use of radioactive material without approval by the UIC. Normally only faculty members are approved to supervise radioactive material laboratories, however the UIC may make exceptions to this policy.

Principal investigators are required to register all generally licensed radioactive material with EHS. The Generally Licensed Radioactive Material Registration Form is available at the EHS website. No one may use generally licensed radioactive material until the material is registered with EHS.

Individual Users

Each individual user, including each supervisor, is ultimately responsible for the safe use of all radioactive material to which he or she has access. Users must obtain training from EHS and must pass the exam at the end of this training. Each individual must perform all work according to the scope and limits of the Authorization to Use Radioactive Material. Each individual shall read, be familiar with, and comply with all sections of the Rules and Procedures applicable to his or her work.

TRAINING:

Faculty or staff who supervise students or staff who work with specifically licensed radioactive material must have an authorization for the use of that material approved by the UIC. Faculty must have experience working with radioactive material before they can be approved to supervise a laboratory. This experience is required so supervisors understand the difficulties and restrictions inherent in working with radioactive material. The UIC will arrange to provide the necessary training and experience for those who need hands-on experience.

Supervisors and users of specifically licensed radioactive material must meet minimal training requirements as specified in the Rules and Procedures.These include the initial training required prior to beginning work with radioactive material, annual retraining, and any special training required by the UIC.

Persons who do not work with radioactive material but work in areas in which radioactive material is used (dish washers, administrative assistants, and custodial staff) shall review Radiation Safety for Ancillary Personnel. This pamphlet can be obtained from the EHS office or from the EHS web site. It is the responsibility of the supervisors of such workers to see that each individual has reviewed and understood the material in this publication.

Registrants of generally licensed sources will be given individual training concerning the requirements of the particular source(s). Personnel who work in the area of generally licensed sources should review the Radiation Safety for Ancillary Personnel information on the EHS web site.

ACQUISITION, STORAGE, TRANSFER, AND DISPOSAL OF RADIOACTIVE MATERIAL:

All acquisition and transfer of specifically licensed radioactive material must receive prior approval from Environmental Health and Safety. All radioactive material must be delivered to 228 Academic Projects Building unless EHS explicitly agrees to an alternative. EHS staff will ensure that the material is obtained, documented, and surveyed in accordance with applicable regulations.

Radioactive material falls into many different categories (source material, by-product material, naturally occurring radioactive material, accelerator produced material, generally licensed, specifically licensed, and four kinds of exempt material). These categories sometimes overlap, for this reason it is imperative that EHS be contacted prior to purchasing any radioactive material.

The acquisition of specifically licensed radioactive material must have authorization by the UIC prior to purchase or transfer to Penn State.

Generally licensed radioactive material must be registered with EHS when it is received. Contact EHS prior to acquiring or disposing of this material for assistance in handling federally mandated paperwork.

Licensed radioactive material must be used, stored, and disposed in accordance with the UIC's Rules and Procedures for Users of Radioactive Material or in accordance with the instructions provided with the generally licensed material.

USE OF RADIOACTIVE MATERIAL:

Specifically licensed radioactive material may only be used in accordance with specific written authorizations approved by the University Isotopes Committee and in accordance with all applicable requirements of the Rules and Procedures for Use of Radioactive Material at The Pennsylvania State University. Contact Environmental Health and Safety EHS at 814-865-6391 for assistance in completing the application.

Generally licensed radioactive material may only be used in accordance with the manufacturer's instructions and at the location specified in the EHS registration.

Nuclear Regulatory Commission regulations forbid combining multiple license exempt sources to make one larger source, and combining license exempt sources with other radioactive materials. License exempt sources may only be used for the purpose for which they were manufactured.

EMERGENCIES:

In case of emergencies, follow the emergency procedures detailed in the Rules and Procedures. Contact EHS at 814-865-6391 if you are not familiar with those procedures or would like additional information or help.

FURTHER INFORMATION:

For questions, additional detail, or to request changes to this policy, please contact the Director of Environmental Health and Safety.

CROSS REFERENCES:

Other Policies in this manual should also be referenced, especially the following:

SY01 - Environmental Health and Safety Policy

SY15 - Radiation-Producing Instruments

SY20 - Hazardous Waste Disposal

SY29 - Infectious Waste Disposal

BS14 - Penn State Purchasing Card

Most recent changes:

• January 13, 2023 - Editorial change to update Policy Steward.
• January 6, 2022 - Changed Subject Matter Expert.

Revision History (and effective dates):

• September 13, 2019 - Changed Vice President for Research to Senior Vice President for Research

• March 12, 2019 - Editorial changes. In RESPONSIBILITIES, revised from “ Office of Environmental Health and Safety" to “Department of Environmental Health and Safety"; and revised from "Receive and ship" to "Oversee receipt and shipment of". In both PURPOSE and APPLICABILITY, revised from "at all Penn State locations except for the Hershey Medical Center" to "at all Penn State locations except for the Hershey Medical Center, and the College of Medicine". in TRAINING, revised from "janitors" to " and custodial staff". In ACQUISITION, STORAGE, TRANSFER, AND DISPOSAL OF RADIOACTIVE MATERIAL, revised from "228 Academic Projects Building" to "228 Academic Projects Building unless EHS explicitly agrees to an alternative".

• June 11, 2014 - Editorial changes. Minor, but clarifying changes made in REFERENCES section for applicable NRC regulations. In RESPONSIBILITIES, revised Title from “Vice President for Research and Dean of the Graduate School” to “Vice President for Research” to reflect position changes. Added policy steward/ further information references, in the event that there are questions or requests for changes to the policy.
• March 12, 2010 - Editorial changes. In RESPONSIBILITIES, clarified financial responsibilities for license fees in section pertaining to Principal Investigators (verbiage added to first paragraph).
• January 1, 2010 - Editorial changes. In RESPONSIBILITIES, Title changed FROM "Senior Vice President for Research and Dean of the Graduate School" TO "Vice President for Research and Dean of the Graduate School," to reflect position changes, effective January 1, 2010.
• November 8, 2006 - Editorial change - changed Vice President for Research to Senior Vice President for Research in RESPONSIBILITIES.
• January 17, 2003 - New Policy.