Objective

This procedure establishes the management of generally licensed (GL) devices used on the UTHSC campus.

Scope

This procedure applies to all devices obtained by campus supplied as generally licensed devices. This procedure establishes the roles and responsibilities of all campus personnel that manage or use generally licensed devices.

Roles

Device owner – the UTHSC employee that is the primary user of the of the GL device Research Safety Affairs Office – maintains GL device safety and compliance data, tracks GL devices on campus, serves at the point of contact with the TN Department of Radiological Health, manages the facility GL license, and disposes of GL devices.

Definitions

Generally Licensed (GL) Device – a device that contains radioactive material that can be sold or provided to the end user with the user obtaining a radioactive materials license prior to receiving the device. (The end user must obtain a general license from the Tennessee Division of Radiological Health after the device is received.) Examples of generally licensed devices on campus include tritium exit signs and liquid scintillation detectors. A generally licensed device will be labeled with information that includes:

1. “Caution – Radioactive Material” and radiation symbol

2. Manufacturer and model number
3. Additional safety information

Procedure

1. Device owner responsibilities-
   1. Contact Research Safety Affairs (901-448-6114) before purchasing the device. Provide the following information:
      1. Campus owning department
      2. Department contact/owner
      3. Location of use or storage (if a mobile device)
      4. Manufacturer and model number
      5. The purchase order number
      6. Brief description how the device will be used
   2. Contact Research Safety Affairs when the device arrives on campus.
   3. Contact Research Safety Affairs if the device will be moved to another location on campus or is transferred to another campus user.
   4. Contact Research Safety Affairs if the device is no longer needed and ready for disposal.
      1. The radioactive source must be removed before handing the device over to property control.
      2. If the device will be to the manufacturer for disposal, contact Research Safety before shipping the unit off campus.
2. Research Safety Affairs Responsibilities-
   1. Upon arrival, ensure the device is added to the UTHSC general license (GL-406) by Tennessee Division of Radiological Health
      1. Contact Makalia Mynatt email: makalia.mynatt@tn.gov phone: 615-854-5976 address: 711 R.S. Gass Blvd. Nashville, TN 37243
   2. Program audit responsibilities
      1. Quarterly physical inventory of all GL devices
         1. Complete the inventory form
         2. Report any missing GL devices to the RSO immediately.
         3. Sign and date the form
         4. File the inventory form per the Document Management Procedure
      2. Annual review and confirm compliance with the TDEC GL Inspection Report
         1. Review the annual inventory form received from TDEC to ensure it is accurate and complete
         2. Walk down the GL devices and verify they are on campus at the designated locations.
            1. Note and new locations and update EHSA and the GL inventory.
            2. Report any missing GL devices to the RSO immediately.
         3. Sign and date the form
         4. File the inventory form per the Document Management Procedure
      3. Disposal of GL Devices
         1. When a request from the GL owner to dispose of the device, collect the information on the unit including the line number for the unit from license GL- 406.
         2. Determine the best disposal option of the device–
            1. Ship via the radioactive waste vendor, or
            2. Return to the manufacturer
         3. When shipped, send a request to the TN Division of Radiological Health at the address listed in II.A.(a) requesting the removal of the disposed device from the license.
            1. Include the documentation of disposal with the request.
            2. Retain the documentation received back from the Tennessee Division of Radiological Health.
            3. File the inventory form per the Document Management Procedure
      4. Inventory of GL devices
         1. A quarterly inventory of all campus generally licensed devices will be conducted by physically walking down each device.
            1. Verify (and correct if necessary) the following information found in EHSA for each device-
               1. The owner
               2. The owning department
               3. The serial number, model number, and manufacturer
               4. The status of the unit
                  1. Active
                  2. Inactive (obsolete, nonfunctional, or no longer needed)
               5. The UTHSC inventory number if available
            2. File the inventory form per the Document Management Procedure
         2. Conduct a semi-annual leak test on any generally licensed device that requires a leak test.
      5. Addition of a new GL device –
         1. Complete a GL Device Receipt Form
         2. Add the New device into EHSA GL Device list
         3. Ensure GL device owner is entered into personnel section and is licensed as a GL device owner. GL device owners do not have to complete an application in iMedris.
         4. Update the sealed source leak testing list if device requires a leak test per the device manual or label
         5. File the receipt form per the Document Management Procedure
3. Documentation
   1. Receipt inspection form

Penalties/Disciplinary Action for Non-Compliance

License violations are subject to civil penalties up to $5,000 per day per violation. In the event of a threat to public health and safety, the Division has the right to confiscate radiation sources.

References

1. Tennessee Administrative Code Title 0400 – Environment and Conservation Subtitle 0400-20 – Division of Radiological Health (§§ 0400-20-04-.01 — 0400-20-13-.08)
2. NUREG 1556 Volume 16 Revision 1
3. GL-406

Responsible Official & Additional Contacts

This Responsible Official and Additional Contacts section contains those who are responsible or share certain policy responsibilities, organized by subject matter, such as monitoring compliance with the policy, providing additional guidance on policy clarifications, organizing policy training, updating the policy, etc.

Subject Matter	Office Name	Telephone Number	Email/Web Address
Policy Clarification and Interpretation	Research Safety Affairs	(901) 448-6114	radsafety@uthsc.edu
Policy Training	Research Safety Affairs	(901) 448-6114	radsafety@uthsc.edu

Related Policies/Guidance Documents

1. Tennessee Administrative Code Title 0400 – Environment and Conservation Subtitle 0400-20 – Division of Radiological Health (§§ 0400-20-04-.01 — 0400-20-13-.08)
2. NUREG 1556 Volume 11 Revision 1
3. DRH- General License 2848