RSP04 Radioactive Materials Laboratory Audit and Survey Procedure

Objective

This procedure establishes audit procedures conducted by Radiation Safety Personnel in laboratories authorized for radioactive materials use, GL device use, sealed source use, research laser use, and research MRI use.

Scope

This procedure has been developed and implemented by UTHSC Research Safety Affairs applies to all areas where radioactive materials are used or stored.

Roles

Research Safety Affairs personnel will conduct and document audits in accordance with this procedure.

Definitions

Procedure

  1. Laboratory personnel responsibilities:
    1. Grant reasonable access to areas where radioactive materials are used or stored.
    2. Address concerns or inspection findings in a timely fashion.
    3. Participate in the inspection to ensure laboratory records and radioactive materials application are current.
  2. Research Safety Affairs responsibilities-
    1. All campus locations where radioactive materials are used or stored will be audited per this procedure at least quarterly. Time between inspections will not exceed 90 days.
    2. The following safety/compliance items will be reviewed/collected and documented during the inspection in accordance with the Laboratory Inspection Guide-
      1. Review and update if needed the laboratory roster of personnel.
      2. Review previous audit and note any deficiencies/concerns/findings.
      3. Review training records
      4. Review inventory records
      5. Review dosimetry records
      6. Review the laboratory survey records
      7. Inspect waste handling and inventory.
      8. Inspect radioactive materials security.
      9. Inspect radioactive materials inventory.
      10. Inspect laboratory survey instrument(s).
      11. Verify laboratory signage is compliant.
      12. Verify required shielding is present and used properly
      13. Verify lab has appropriate PPE and is using it properly
      14. Verify lab has a spill kit properly stocked
      15. Verify lab has an appropriate means of analyzing wipes and does it properly.
      16. Conduct a survey of the laboratory spaces
      17. Conduct special survey if applicable
      18. Inventory any generally licensed devices
      19. Review compliance with the authorized user IMEDRIS approved application
      20. Review EHSA data and ensure the data is accurate and up-to-date
    3. The findings will be documented on the Field Radiation Inspection Form, and an audit report will be prepared in accordance with the Laboratory Inspection Guide. The audit report will be reviewed and approved by the Radiation Safety Officer.
    4. The Radiation Safety dashboard will be updated.
    5. The approved report will be sent to the laboratory authorized user/PI and will be filed away in accordance with the Document Retention Procedure.
  3. Research Safety Affairs Pre-Audit Activities
    1. Generate a copy of the current authorized user/PI IMEDRIS application.
    2. Generate a copy of the current EHSA authorized user/PI data.
    3. Generate a list of lab personnel with dosimeters and the exposure data for the past 12 months and a list of badges returned late or lost badges.
    4. Retrieve a copy of the previous quarter audit report.
    5. Create or retrieve lab sketches for each radioactive materials lab or work area.
    6. Complete the pre-audit inspection portion of the Field 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. NUREG 1556 Volume 11 Revision 1
  2. License R-79019-D30

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. License R-79019-D30

RSP04 Radioactive Materials Laboratory Audit and Survey Procedure
Version: 1 // Effective: 01/13/2025
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