UTHSC Radiation Safety Committee – Authority, Functions, and Membership

No./Title: UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER RADIATION SAFETY COMMITTEE AUTHORITY, FUNCTIONS AND MEMBERSHIP

Resp. Office: RESEARCH

Effective Date:

03/14/2022

Category: Compliance

Last Review: 3/24/2019

Next Review:

03/14/2025

Contact: Steven L. Youngentob, PhD, Senior Associate Vice Chancellor for Research

Phone: 901.448.1278

syoungen@uthsc.edu

Related Policies:

NA

PURPOSE

To document the authority, function and membership of the University of Tennessee Health Science Center Radiation Safety Committee (RSC).

BACKGROUND

As required by the Rules of the Tennessee Department of Environment and Conservation, Division of Radiologic Health (Chapter 0400-20-10, Section -.13) and the Nuclear Regulatory Commission Regulations (10 CFR, Part 33.13), an institutional radiation safety committee (RSC) has been established by the administration of UTHSC. This committee has the general responsibility to oversee the proper and safe use of all sources of ionizing radiation and non- ionizing radiation known to present a potential hazard to human health (including lasers). In this respect, the RSC recommends policy and procedures to the university for the procurement, and safe and legal use of radioactive materials, or other forms of ionizing radiation and non- ionizing radiation in the areas of research, teaching, and other university work. Moreover, on behalf of the university, the RSC meets to review reports on the receipt and disposal of radioactive materials/radiation-producing devices, and to act on applications and amendments for authorization to use these sources.

ORGANIZATIONAL STRUCTURE

Per UTHSC’s Broad Scope License R-79019, the Radiation Safety Committee reports to the Vice Chancellor for Research through the Senior Associate Vice Chancellor. The Radiation Safety Officer, while working collaboratively with the RSC to ensure a safe and compliant program, reports directly to the Director of Research Safety Affairs. The Director also works collaboratively with the RSC to ensure a safe and compliant research program.

PROCEDURES

  1. Committee Membership
    1. Composition: Members include the Radiation Safety Officer (RSO), a representative of the business office, a representative of management, and one or more persons trained or experienced in the safe use of each modality of ionizing or non-ionizing radiation (including lasers) utilized on the UTHSC Memphis campus.
    2. Membership Appointment: Membership on the UTHSC RSC is a privilege and a responsibility granted by invitation to scientific and non-scientific members of the academic and local community by the Vice Chancellor for Research or their designee. All appointments are for an initial three-year term, and may be reappointed for successive terms, at the discretion of the Vice Chancellor or their designee.

      All prospective appointments will be evaluated for potential RSC membership by the Vice Chancellor or their designee based on the following:
      1. Evidence of education and training in the area of radiation safety (as documented in his/her CV or resume)
      2. Specific needs of the RSC

        A member may be removed, with or without cause, from the RSC:
      3. By the action of the Vice Chancellor for Research or their designee, on the recommendation of the Chair.
      4. Automatically, if the member misses 3 consecutive meetings or has a pattern of non-attendance.
    3. RSC Chair Appointment: The Chair is a member of the RSC whose experience and expertise are documented in his/her CV. The Chair is appointed by the UTHSC Vice Chancellor for Research or their designee. The Chair will serve a term of three years and may serve successive terms at the discretion of the Vice Chancellor for Research or their designee. Removal of the Chair may be accomplished by his/her resignation in writing, or by written notification of termination (with or without cause) of the appointment by the Vice Chancellor for Research or their designee.
  2. Meetings
    1. Frequency: The Radiation Safety Committee shall meet as often as necessary to conduct its business but not less than once each calendar quarter and must have a quorum present to conduct official business.
    2. Quorum: A quorum shall consist of at least a majority of the voting committee membership, including the Radiation Safety Officer and, at least one of the representatives from Administration (i.e., management or business).
  3. Responsibilities
    1. Chair: The Chair will perform functions including, but not limited to the following:
      1. Direct the proceedings of the full RSC. The position of Chair is a voting position.
      2. Enforce UTHSC RSC policies and standards, as well as all applicable state and federal rules, regulations and statutes concerning radiation safety, use and disposal.
      3. Oversee the review of all protocols and amendments submitted to the committee.
      4. Oversee the review of violations of the UTHSC Radiation Safety Program, as well as applicable state and federal laws and regulations.
      5. Ensure transparency in the conduct of all Committee meetings, including providing meeting agendas, and documenting members present, numerical results of all votes taken, and dissemination of written meeting minutes.
    2. Committee Members:
      1. Review at least quarterly the Radiation Safety Officer’s summary report of occupational radiation exposure records of all personnel working with radioactive materials.
      2. Provide professional advice to the Radiation Safety Officer on matters regarding radiation safety.
      3. Review and approve all requests for the use of radioactive material or other forms of radiation within the institution.
      4. Prescribe special conditions that will be required during a proposed use of radioactive material or other forms of radiation within the institution such as requirements for bioassays, physical examinations of users, and special monitoring procedures.
      5. Review the RSO’s annual evaluation of the radiation safety program at least annually to determine that all activities are being conducted safely and in accordance with UTHSC policies, as well as state and federal regulations, and the conditions of UTHSC’s Broad Scope license.
      6. Recommend remedial action to correct any deficiencies identified in the radiation safety program.
      7. Ensure that UTHSC’s radiation safety program complies with state and federal regulations, as well as institutional policy.\
      8. Review instances of non-compliance by authorized users, and take corrective action, as appropriate, per policy.
      9. In collaboration with the RSO, formulate and recommend policy in the use of radioactive materials and other sources of radiation.
  4. Radiation Safety Officer’s Responsibilities and Relationship to the RSC
    1. Implement and maintain the Radiation Safety Program as described in the Position Description for the Radiation Safety Officer and in the Delegated Authority under UTHSC’s Broad Scope License.
    2. Ensure that all individuals who work with and/or in the vicinity of radioactive material etc. have sufficient training and experience to enable them to perform their duties safely and in accordance with UTHSC policy and the conditions of UTHSC’s Broad Scope License.
    3. Ensure that all use of radiation sources is conducted in a safe manner and in accordance with current regulations and the conditions of UTHSC’s Broad Scope License.
    4. Review the training and experience of all individuals who use radioactive material and radiation sources, and determine that their qualifications are sufficient to enable them to perform their duties safely and in accordance with applicable UTHSC policies and state and federal regulations and the conditions of UTHSC’s Broad Scope License.
    5. Review occupational radiation exposure records of all personnel working with radioactive materials at least quarterly and report these records to the RSC.
    6. Review and approve all requests for acquisition of radioactive material or other forms of radiation within the institution.
    7. Review and evaluate the performance of the entire radiation safety program at least annually to determine that all activities are being conducted safely and in accordance with UTHSC policies, as well as state and federal regulations and the conditions of UTHSC’s Broad Scope License.
    8. Audit the work areas of all Authorized Users at least annually and report findings to the RSC.
    9. Provide remedial action to correct any deficiencies identified in the radiation safety program.
    10. Report instances of non-compliance and the enforcement of corrective actions to the RSC, per policy.
    11. Ensure that UTHSC’s Broad Scope License is amended, when necessary, prior to any changes in facilities, equipment, policies, procedures, radioactive material, possession limits, and personnel, as specified in the license.
  5. Record Keeping:

    All meetings of the RSC will be recorded and transcribed in order to create and maintain a written record of all Committee discussions and actions, including a record of members present, members absent, non-voting members present, and the numerical results of all votes taken.
  6. Ex Officio
    1. Vice Chancellor for Research
    2. Senior Associate Vice Chancellor for Research
    3. Director of Research Safety Affairs
UTHSC Radiation Safety Committee – Authority, Functions, and Membership
Version: 1 // Effective: 03/14/2022
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