SEC-009: Utilization of Radioactive Materials

Date: 08/01/2005 Status: Final
Last Revised: 09/27/2011
Policy Type: University
Oversight Executive: Vice President for Research
Applies To: Academic Division and the Medical Center.
Reason for Policy:

The University has established its own Radiation Safety Program. This Program is a requirement of the University’s Commonwealth of Virginia Radioactive Materials licenses that permits the use of radioactive materials at the institution.

Policy Summary:

The Radiation Safety Program includes implementation procedures to ensure the security and safe use of all licensed material at the University. Only appropriately trained personnel will handle and use licensed material without undue hazard to themselves, other workers or members of the public. The Radiation Safety Committee is authorized to approve all acquisition, use, location and storage of radioactive materials.

Definition of Terms in Statement:
  • Licensee:

    The University as a recipient of a license issued under the regulations in the Virginia Administrative Code (VAC) 12 VAC5-481.

  • mSv/mrem:

    Units used to express a quantity of radiation dose.

Policy Statement:

All University faculty, staff, students and Medical Center employees using ionizing radiation producing sources or equipment must adhere to the following provisions:

  1. Radiation Safety Program:
    In accordance with applicable regulations , the University of Virginia has developed, documented, and implemented a radiation protection program commensurate with the scope of its licensed activities. The program is sufficient to ensure compliance with provisions of Part 20 regulations. The University is responsible for the conduct of all licensed activities. As a licensee, the University is required to keep radiation doses to workers and members of the public ALARA (As Low As Reasonably Achievable), ensure security of licensed material and make required notifications to the Commonwealth of Virginia's Department of Health/Radiological Health Division (the State) of certain events.

    Procedures have been developed and implemented to ensure the security and safe use of all licensed material from the time it arrives at our institution until it is used, transferred, and/or disposed. The written procedures provide reasonable assurance that only appropriately trained personnel will handle and use licensed material without undue hazard to themselves, other workers, or members of the public.

    As a broad scope licensee, the University must also maintain a Radiation Safety Committee (RSC), which works with executive management and the Radiation Safety Officer (RSO) in implementing the radiation safety program and establishing policies and procedures for managing the radiation safety program.

    The RSC is composed of such persons as the RSO, executive management and persons trained and experienced in the safe use of radioactive materials. Each area of use under the license should be represented on the RSC.

    The RSO performs audits of all areas of use and individuals who are authorized to use byproduct material to ensure work is done in accordance with the license, regulations, and user permit conditions. Specific duties and responsibilities performed under the radiation safety program include:

    • Monitoring and surveys of all areas in which radioactive material is used;
    • Oversight of ordering, receipt, surveys, and delivery of byproduct material;
    • Packaging, labeling, surveys, etc. of all shipments of byproduct material leaving the institution;
    • Personnel monitoring program, including determining the need for and evaluating bioassays, monitoring personnel exposure records, and developing corrective actions for those exposures approaching maximum permissible limits;
    • Training of all personnel;
    • Waste disposal program;
    • Inventory and leak tests of sealed sources;
    • Decontamination;
    • Investigating any incidents and responding to any emergencies; and
    • Maintaining all required records.

The University must ensure that licensed material will be used, transported, stored and disposed in such a way that the total effective dose equivalent (TEDE) to members of the public will not exceed more than 1 mSv (100 mrem) in one year, and the dose in any unrestricted area will not exceed 0.02 mSv (2 mrem) in any one hour.

  1. Training:
    Untrained workers represent a potential hazard to themselves, other individuals and property. Before beginning work with or in the vicinity of licensed material, all individuals who are likely to receive an occupational dose in excess of 1 mSv (100 mrem) in a year must receive radiation safety training commensurate with their assigned duties and specific to the University’s Radiation Safety Program. Each individual should also receive annual refresher training.

    It will not be assumed that safety instruction has been adequately covered by prior employment or academic training. Practical, site-specific training will be provided for all individuals prior to beginning work with or in the vicinity of licensed material.

    Retraining should be performed whenever there is a change in duties or the work environment and at a frequency sufficient to ensure that all staff members are adequately trained.

  2. Security of Radioactive Material:
    All licensed materials that are stored in controlled or unrestricted areas will be secured from unauthorized access or removal, so that individuals who may not be knowledgeable about radioactive materials cannot be exposed to or contaminated by the material, and individuals cannot take the material. When licensed materials are in use in controlled or unrestricted areas, they must be under constant surveillance so that the radiation worker can prevent others from becoming contaminated by or exposed to the material, or prevent persons from removing the material from the area. A questions and answer fact sheet regarding security may be viewed at EHS - Radiation Safety.

  3. Radiation Accident/Emergency:
    Environmental Health and Safety (EHS) has established written procedures to handle emergencies ranging from a normal spill to a major accident that may require intervention by outside emergency response personnel. These procedures include provisions for immediate response, and after-hours notification. EHS will post emergency procedures in all use areas. Guidance on basic emergency procedures for radioactive spills may be obtained by accessing the Radiation Safety Guide.

    Information on response to a terrorist act involving radioactive material may be obtained by accessing the information contained in Radiation Safety.

  4. Radioactive Waste:
    The University must ensure the safe use and handling of all licensed material from the time it arrives at UVa until is used, transferred or disposed. Environmental Health & Safety maintains a disposal program that includes procedures for handling of waste, safe and secure storage, waste characterization, waste minimization and disposal of radioactive waste. Appropriate training is provided to waste handlers.

    The University cannot receive radioactive waste from other licensees for processing, storage, or disposal unless specifically authorized by the State.

    The waste program also includes mechanisms for reducing hazardous waste and mixed waste and monitoring and segregating waste materials, e.g. radioactive from nonradioactive, short from long half-life, liquid from solid waste, etc. All waste is disposed in accordance with applicable federal and state regulations. Annual radiation safety and waste handling training is required for all faculty, staff and students who work with radioactive material. The Radiation & Chemical Safety Annual Refresher Training is available on-line..


Detailed procedures for each policy above can be found on the Environmental Health and Safety website.

Related Information:

SEC-010, Radiation Protection during Pregnancy and Pregnancy Declaration

Policy Background:

This is the first version of this policy.

Major Category: Safety, Security and Environmental Quality
Approved by, Date: Executive Vice President and Chief Operating Officer, 08/01/2005
Revision History: Updated 9/27/11, 8/25/2008.