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by schmidy last modified Jun 27, 2007 02:04 PM

Authority and Responsibility of Radation Safety Committee

Convening Authority and Composition

The President of the University of Louisville, upon recommendation of the Dean of the Medical School, Vice President for Research, Vice President for Administration and the University Provost, shall appoint a University Radiation Safety committee.  The committee shall consist of at least ten (10) members, plus ex-officio representatives.  The membership shall, at the minimum, include representatives from University administration, representatives from university administration and nursing service, the University Radiation Safety Officer and University faculty members.  The membership requires expertise in the following areas:

  1. Research (Non-human) Use Sub-committee (3 members)
    • Concerned with protection and safety aspects of radioactive materials use in the research environment; including contamination control, ventilation proper waste disposal and safety aspects and training of lab personnel as well as approval of research protocols involving in-vitro radioactive materials use and in-vivo use of radionuclides in animals.

  2. Human Use Sub-committee (3 members)
    • Concerned with protection and safety aspects of radionuclide use in the clinical setting, including all areas of radiation safety for patients and occupationally exposed personnel and approval of authorization applications and human useprotocols.

  3. Ionizing and non-ionizing radiation producing machines (1 member)
    • Concerned with protection and safety aspects of machines and instruments that produce ionizing and non-ionizing radiation, including proper shielding of operators and training.

  4. U of L hospital administration nursingservices (2 members)
    • Concerned with radiation safety issues of patient care as well as nursing service.

  5. University Administration (1 member)
    • Concerned with radiation safety issues regarding University faculty/staff and students as well as research grant activity.

  6. University Radiation Safety Officer
    • Ex-officio member providing radiation safety expertise to all committee members.

  7. Other ex-officio members as deemed necessary by the committee.
    • Members from other University areas where radioactive material is used or stored who can provide assistance to the committee as requested.

The membership of the committee, both voting and ex-officio shall be selected to provide expertise in each of the areas of clinical and research uses of radiation outlined above. Collectively, the members of this committee must have the capability of assessing the safety of research projects, human use involving radionuclides and the use of both ionizing and non-ionizing radiation producing machines.  Appointments to the committee will be for a minimum of three (3) years.

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General Purpose

The Radiation Safety Committee has two main charges:

  1. Ensuring that all individuals who work with or in the vicinity of radioactive materials or radiation have sufficient training and experience to enable them to perform their duties safely and in accordance with Kentucky Cabinet for Human Resources regulations 902KAR:100, conditions of the radioactive material licenses, tenants of the Radiation Safety Manual and good radiation safety practice.

  2. Ensuring that all use of radioactive material and radiation is conducted in accordance with Kentucky 902KAR:100 regulations, license conditions, and radiation safety manual policy and procedure. The goal of this committee shall be to facilitate clinical uses of radiation by providing expedient review of the Radiation Safety Program and to address the requirements of any applicable regulatory agencies. In order to ensure that research and patient care is not hampered by this review, all necessary administrative support will be given to this committee.

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Specific Duties

The University Radiation Safety Committee shall:

  1. Be familiar with all pertinent regulations, the terms of the license, the radiation safety manual and information submitted in support of the request for amendments to authorizations for the use of radionuclides and radioactive material licenses.

  2. Review the training and experience of all individuals who use radioactive material (including clinicians, researchers, physicists and pharmacists) and determine that their qualifications are sufficient to enable them to perform their duties safely and in accordance with Kentucky 902KAR:100 regulations, license conditions and radiation safety manual policy and procedure.

  3. Establish a program to ensure that all individuals whose duties may require them to work in the vicinity of radioactive materials (e.g. lab technicians, nursing personnel, physical plant, custodial and security personnel) are properly instructed as required by 902KAR 100:165, Section 2.

  4. Review all requests for use of radioactive materials within the University.

  5. Approval of research grant proposals that involve the use of radiation in animals.

  6. Prescribe special conditions that will be required during a proposed use of radioactive materials such a bioassay, physical examinations of users and special monitoring procedures.

  7. Review the entire radiation safety program annually to meet ALARA requirements and determine that all activities are being conducted safely and in accordance with Kentucky 902KAR:100 regulations, license conditions, and radiation safety manual policy and procedure.

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

  9. Maintain written records of all committee meetings, actions, recommendations, and decisions.

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

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Administrative Procedures

  1. The new policies and procedures recommended by the committee shall be carried out and monitored by the University Radiation Safety Office and any other individuals or offices designated by Vice President for Administration. The Committee Chairman and University Radiation Safety Officer will sign off on proposals needing institutional review for radiation safety concerns.

  2. The Chairman will sign-off on approved grant proposals and new policy and procedure which have been affirmed by committee vote.

  3. All members of the University Radiation Safety Committee meet as often as necessary to carry out its duties, but at least each calendar quarter.

  4. To establish a quorum, 50 percent of the committee's membership, including the University Radiation Safety Officer and the member from University administration must be present.

  5. Approval of motions shall require a majority of those present.

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Radiation Safety Officer (RSO)

The RSO is responsible for the administration of the radiation safety program and is delegated the necessary authority to carry out his/her responsibilities by the Radiation Safety Committee.  Arrangements may be made as needed for radiation safety consultants to supplement the RSO in conducting surveys, waste management and general radiation safety matters.  The authority and responsibility of the RSO shall include, but is not limited to, the following:

  1. General supervision of procurement, receipt, storage and record keeping of radioactive material and sources.
  2. Instruction of personnel in radiation safety.
  3. Conducting investigations of incidents and reporting to the Radiation Safety Committee.
  4. Authority to terminate immediately a project or activity which is a threat to health or property.
  5. General surveillance over all radiation source activities and consultative radiation safety services.
  6. Quarterly review of personnel monitoring records for regulatory compliance and ALARA commitments.

  7. Periodic review of radiation safety documentation (i.e. sealed source leak tests and inventories and surveys).

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