550-28: Radiation Safety

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Overview

Describes UCSF Radiation Safety Committee and responsibilities for the use of any and all sources of ionizing radiation at UCSF facilities.

Purpose

This policy establishes guidelines and responsibilities for the use of any and all sources of ionizing radiation at UCSF facilities.

Definitions

Gamma and x-rays, alpha and beta particles, neutrons, protons, high speed electrons, and other nuclear particles; but not sound, micro-, or radio-waves, or visible, infrared, or ultraviolet light.

Policy

A. The Radiation Safety Committee (RSC) is authorized by the Chancellor to oversee the use of any and all sources of ionizing radiation covered by the Type A Broad Scope Radioactive Materials License issued to UCSF by the Radiologic Health Branch of the California Department of Health Services. This license authorizes UCSF to procure and use radioactive materials in specified areas, including satellite facilities. The license is contingent upon the existence of both the committee, which is regarded as the body of corporate responsibility for radiation safety, and a campus radiation safety office (a function of the Office of Environmental Health and Safety).

B. All research use or non-routine diagnostic or therapeutic use of ionizing radiation at UCSF must be approved by the RSC.

Responsibilities

A. Executive Vice Chancellor

The Executive Vice Chancellor appoints the RSC, in compliance with state requirements.

The Executive Vice Chancellor has delegated the daily operations regarding radiation safety to the Associate Vice Chancellor for Research.

B. Radiation Safety Committee

It is the responsibility of the RSC to:

1. Advise the Chancellor on all matters related to radiation safety and recommend policies and procedures deemed appropriate to protect the safety of patients, students, employees, and the public;

2. Review all technical and safety-related aspects of the use of all sources of ionizing radiation within the jurisdiction of UCSF, including radiation-producing machines and equipment;

3. Promulgate a radiation safety program that satisfies the condition of UCSF's Broad Scope Type A License;

4. Regularly review the monitoring program conducted by the Office of Environmental Health and Safety, and report on such monitoring as may be required by the state;

5. Assure the observance of all safety standards established by the Nuclear Regulatory Commission, California Department of Health Services, National Council on Radiation Protection and Measurements, and other duly recognized regulatory and standard-setting bodies;

6. Limit or withdraw, as authorized by the Chancellor, investigators’ authority to use radioactive materials or sources of ionizing radiation if such use presents a hazard to individuals or violates health and safety codes.

C. Radiation Safety Officer

The radiation safety officer in the Office of Environmental Health and Safety provides laboratory inspection and approval, consultation, and education.

D. Principal Investigator

It is the responsibility of the principal investigator to:

1. Comply fully with all aspects of the UCSF radiation safety program and any conditions that may be required by the RSC;

2. Report immediately to the radiation safety officer any accidental spill or release of radiation or any accidental personal exposure to radiation of laboratory or other personnel.

References