1. UNM Chart – Radiation Safety
2. Suggested Committee Representations (Guide)
3. Emergency Contacts
4. Courses and Orientations
5. Forms

6. HUS Research Project Submission Form
7. New Mexico Radiation Protection Regulations

Subpart 4. Standards for Protection Against Radiation (including Appendix B only)
Subpart 10. Notices, Instructions and Reports to Workers: Inspections

Suggested Committee Representations (Guide)

1. Radiation Control Committee

1. Chairman and Co-chairman
2. Representatives from Basic Science (Biology, Chem., Physics)
3. Engineering Representative
4. Radiology Representative
5. Human Uses Subcommittee Chairman
6. Faculty Senate
7. Radiation Safety Officer (Non-voting)

2. Human Uses Subcommittee (Chairman selected from membership)
1. Radiation Therapy Representative
2. Pathology Representative
3. Hematology Representative
4. Radiation Physics Representative
5. Pediatrics or Ob-Gyn Representative
6. Pharmacy Representative
7. Representative from the Radiation Control Committee
8. Three (3) medically oriented members which are knowledgeable about radiation but are not full-time faculty members of the UNM
9. Radiation Safety Officer (Non-voting)

Courses and Orientations

1. Course Description

1. Introduction to Radiation Safety

1. Knowledge of Basic Physics

2. Methods of Dose Reduction

3. Radiation Detection

4. Biological Effects of Radiation

5. Regulations

2. 230 Radiation Safety Engineering

3. 323L Nuclear Detection and Measurement

4. 401 Introduction to Radiation Protection

5. 491L Radiobiology

2. Custodial Training

RSF-01-1 Permit Application For Use of Radioactive Materials or Radiation-Producing Machines

RSF-10-1 Radioactive Material Check In and Delivery

RSF-53-1 Lost Dosimeter Report

RSF-60-1 Radiation Worker’s Training & Experience

RSF-80-1 Radiation Producing Machines Information

Instructions: Address ALL items listed below (Please PRINT or TYPE). If you have questions, please contact Jim De Zetter/UNM RSO at 505-277-2753 or e-mail jimdz@unm.edu.

1. Identification of person who will use or supervise the use of the material or machine. Include Name, Department, Phone #, Date of Application and any other pertinent information.
2. Have radiation dose records been maintained on personnel previous to this application? If so, list the name, SSN, institution, and dates of monitoring for each.
3. Training and Experience

1. Complete Training & Experience form for each individual who will work with radiation. Indicate type of training, where trained, duration of training, and type of training (i.e. formal or on-the-job).
2. Training of permit applicant must be documented in detail to include previous RSO (name, phone number, address) and previous employment contacts (names, phone numbers, addresses). Also submit a copy of printed publications which may justify training.
3. Written documentation that all permit holders and supervisors have read and understood the applicable UNM and State Regulations regarding the safe use of radiation and radioactive materials is required. Anyone who has not read the appropriate rules and regulations can find them in the current UNM Radiation Safety Manual. All Permit Holders are required to have a Manual available.

4. Radionuclide or Machine

1. Identify the radionuclides (element and mass number of each) to be included in the permit.
2. Indicate the chemical and/or physical forms to be used. Also, list the names of labeled compounds.
3. List the maximum possession limit for each radionuclide requested. This limit must include waste stored in the lab.
4. For sealed source(s) list the manufacturer, model #, activity of each source and a description of the unit.
5. For radiation-producing machines list the manufacturer, model #, output (normal and maximum) and a description of the unit.
6. Describe purpose for which the above items will be used.
7. Describe location(s) where above items will be used.

5. Facilities and Equipment

6. Radiation Protection

1. Describe how the material or machine will be controlled, procedures and/or techniques applied.
2. Describe types of instrumentation and/or methods used to determine external and internal doses of ionizing radiation to personnel. Also describe instrumentation to be used to detect contamination in the laboratory and in uncontrolled areas.
3. Describe potential for radioactive contamination in the laboratory and in uncontrolled areas. Describe precautionary methods which will be employed to prevent contamination of personnel and uncontrolled areas
4. Describe potential for "abnormally high" doses to personnel. Describe precautionary methods which will be employed to prevent "abnormally high" doses to personnel.

7. Waste Disposal

1. Describe how radioactive waste materials will be handled (e.g. inventory, control, storage, record-keeping, etc.).
2. Describe chemical waste which will be included in the radioactive waste.

8. Procurement

9. Submit any other information pertaining to the operation which will assure that the program will be conducted in a safe manner and within applicable rules and regulations.

10. Sign and Date the Permit Application cover page. Submit to:

UNM Radiation Safety Phone # : (505-277-2753)

______________________________________             X________________________________
SURVEYOR                                                                                    RECEIVED BY LABORATORY

Name__________________________________ SS#_____ -____-_______ Date of Birth_____ /____/_______

Department_____________________ Location #_________ Dosimeter #______________ Period______________________

Explain your occupational activities with ionizing radiation and indicate your estimated radiation dose.

The estimate can be based on a previous or subsequent period if the activities were similar.
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________
How was the dosimeter lost?
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

To the best of my knowledge, I believe the above statements are true and the estimated radiation dose may be entered into my exposure record.
 

_________________________________  ______________________
Signature                                                              Date

Send the completed form to:

Date:____________________________

Type of Radiation Machine
 

1. Cabinet X-Ray	11. Electron Microscope	21. Radiography
2. Computed Tomography (Head)	12. Fluoroscopy	22. Radiography, Digital
3. Computed Tomography (Body)	13. Linear Accelerator (1-11.99 MeV)	23. Radiography/Fluoroscopy
4. Dental, Cephalometric	14. Linear Accelerator (12+ MeV)	24. Shielded Room X-Ray
5. Dental, Intraoral (Elec. Timer)	15. Mammography	25. Superficial X-Ray (up to 150 kV)
6. Dental, Intraoral (Hand-held Timer)	16. Miscellaneous Analytical Device	26. X-Ray Diffraction
7. Dental, Multipurpose	17. Open Air X-Ray	27. X-Ray Fluorescense
8. Dental, Panoramic	18. Orthovoltage (151-999 kV)	28. X-Ray Gauge
9. Electronbeam Only (Therapy)	19. Particle Accelerator	29. X-Ray Microprobe
10. Electronbeam Welder	20. Photo Fluoroscopy	30. Other:______________________

Comments:_________________________________________________________________________

Instructions: Each research project submitted to the HUS must be accompanied by the information requested below. To facilitate review, please provide this information in a separate memorandum, which addresses each of the fourteen paragraphs and is numbered and named to correspond to those below.

1. Research Project Title
2. Investigator(s) Name, and name of the responsible university department, contact person(s) name and phone number.
3. Research Objective: Hypothesis which is to be tested
4. Can the research questions be investigated with animal or alternative non-human research models?
5. Study design: State briefly what will actually be done; what measurements will be made; and the duration of the study.
6. Subjects: Describe recruitment methods, numbers, and age groups for each of the relevant categories: patients, controls, healthy volunteers.
7. Substances to be given (i.e., drugs, special diets, radionuclides, vaccines, etc.). State dose, route of administration, frequency, precautions, method of preparation or source of supply, detail assurance of quality control, and what method will be employed to calibrate the dose(s) of radionuclides that will be administered.
8. Samples to be obtained (i.e., urine, blood, cerebrospinal fluid, biopsy specimens, etc.). Give amount and frequency of each type of sample.
9. Other procedures: List any other diagnostic or therapeutic procedure to be employed.
10. Ionizing Radiation (i.e. Radionuclides or Radiation-producing machines): List passage(s) by page number(s) in the protocol and consent form which describe patient exposure, identify type of radiation and report amount of exposure. The Total Effective Dose Equivalent (TEDE) and/or Total Organ Dose Equivalent (TODE) should be used expressed in units of mrem or mSv.
11. Hazards and Risks: Specify toxicity, possible inconvenience, limitation of activity, discomfort, pain, etc., likely to be incurred as a result of participating. State possible risks and injuries to subjects and the probability of their occurrence. Will there be any expense to the subject as a result of participating? Radiation dose risk should be compared with natural background radiation in Albuquerque, NM (i.e., approx. 300 mrem per year).
12. Benefits: List any possible benefits that subjects might derive from participating. Will subjects be paid? If so, how much?
13. Research site(s): Where will the research be carried out? Have the necessary arrangements been made with the facility?
14. The following statement must be on the consent form: The Human Uses Subcommittee may audit the records as needed.

 

 
 
 

To submit a research protocol to the HUS for review, send 10 copies of the Submission Memo, 10 complete copies of the entire protocol, and 10 copies of the consent form(s) to Radiation Safety, 1801 Tucker St., NE, Bldg. 233, UNM Campus.